Patient Rights Advice: PhysioTherapy vs. Aetna Insurance
(Last Updated On: February 10, 2010)
As many of you know, I tore my ACL last year, had surgery and all that jazz. It’s doing fine. I went to PhysioTherapy Associates in Crested Butte for my physical therapy. This particular clinic is not in-network with my Aetna health insurance plan. So, I was given a self-pay rate.
However, when it came time to fit me for a knee brace, I wanted to make sure it was covered. Basically, after having two surgeries in one year, I met all of my in-network deductibles and coinsurance. However, I did not meet my out-of-network deductibles. Aetna DOES cover knee braces for post ACL surgery. But, I was anal and made sure to go through all the proper measures to make sure it was covered. CB Physio Therapy got a pre-authorization number, saying it will be covered. Then, I went down to the PhysioTherapy clinic in Gunnison to be fitted for the brace- I went there because that clinic is in-network, where the CB clinic is not.
A month later, I get a bill from PhysioTherapy saying that my bill for my brace is $1000- when it should have been fully covered- I was not supposed to have paid anything after having met all my deductibles and coinsurance. At first, Physio blamed my insurance company, saying that Aetna couldn’t distinguish between clinics because they all had the same Tax ID #. Well, a call to the right people at Aetna said that Physio had put down the wrong provider ID #. So, I called Physio and told them to resubmit the claim with the correct provider ID #.
Well, my initial knee brace fitting was on July 29, 2009. Here it is, January, and I still don’t have this straightened out. Physio has said they resubmitted claims on 9/16, 11/23 and 12/18. But, Aetna says that they have not resubmitted anything. Honestly, I believe Aetna more that Physio as several of my local Crested Butte friends have had serious billing issues with Physio- and have been lied to. I feel like Physio is lying to me. This is further substantiated by the fact that Physio fails to produce copies of the claims they are sending Aetna to me. I have requested copies of these claims 4 times. I have spoken to the same representatives and also some different representatives (I do know their names)- none producing any proof that claims have actually been sent. Originally, I wanted copies so I could have a better conversation with my insurance company- and even send the copies to them with delivery confirmation for proof that they have actually received the resubmissions. But, now, I want copies just for proof that they’ve done anything at all.
When I call the person in charge at Physio in CB, she simply says the same thing everytime- “Oh, don’t worry. You won’t pay for your brace. We have a preauthorization number.” Despite what I describe to her about the difficulties I’ve been having with Physio headquarters, she does little to help me. She simply thinks it’s not an issue. My brace will be covered.
But, I have been told that if I do not have this issue resolved by 6 months after the original submission, I will not be able to resubmit anymore claims to my insurance company. This is supposedly a standard for insurance companies? Is that true? If so, this date will be on January 29th.
So, what are my legal rights here?
Honestly, I’m pretty much pissed off at Physio beyond belief. Not only did they screw up by placing the wrong provider ID number on the paper work, they have failed to step up to their responsibilities. I have spent countless hours on the phone, trying to correct a mistake they THEY made in the first place. They have done nothing to help me except talk on the phone and make promises that don’t manifest themselves. I feel like I’m talking to some dip-shit sly business guy or something.
Any advice would be deeply appreciated. And BTW, don’t go to Physio Therapy.
Update 1/21
I cannot believe the gross negligence of PhysioTherapy. I called the Gunnison clinic yesterday- she sent a message to “corporate” and nothing happened. “I will call you today to check up on you to make sure somebody called”. That didn’t happen. Nor did anyone call from corporate. I called Gunnison again at 3:30 today and she blamed it on the fact her “computer was down”…. “someone should be calling you today or tomorrow”.
The problem with PhysioTherapy is that messages from individual clinics go off in cyberspace somewhere. Individual clinics don’t really have contact with any specific rep from Phyio’s corporate.
I called the CB clinic. Made the person there send out a message. I told her I felt like Physio’s behavior was ridiculously unprofessional…. I mean, really, how hard is it to send some copies?
Then, I tried to call “corporate” with a 1-866-925-2295. But, instead of saying PhysioTherapy, it answers with “Montgomery Associates”. WTF? It didn’t used to say that. Even more strange is there is no way to talk to a customer service rep. If you wait on the line, it sends you to a voicemail. You have some options to choose, like “If you were treated in Alabama, press 2” or something like that. But, no choice for Colorado. I called the Gunnison clinic and asked what was up w/ that and they had no clue.
Then, I looked up the number for Physio on the Internet- 1-866-786-8482. There, you can’t speak with anybody unless you know specific extensions. So, I left a message on the mass voicemail.
Oh my God, I can’t believe how hard it is to get ahold of these freaking people!!!! Any ideas? I’m seriously about to lose it.
Update 2/5
Leaving that message on the “mass voicemail” got me somewhere. The next day a woman in Pennsylvania called me. Once she realized the issues I’d been having she tried to get me in touch with a woman in Alabama who was supposed to have the capability of helping me. Well, after a few days, the Pennsylvania woman realized that the Alabama woman was no longer with Physiotherapy and then got me in touch with someone else. These two people have been the only people returning my phone calls.
In the meantime, I took matters into my own hands. I called Aetna and kept asking for them to send me to their superior (which, by the way, in Physiotherapy, doesn’t work, because no one knows who their superiors are) until I got someone who actually knew what they were doing. This person went into my claim and put down a corrected claim number and then resubmitted it for me.
I am not sure which method worked- calling Aetna or having Alabama-woman take matters under her control. But, right now, it looks like the claim has gone through and that I don’t owe anything for the brace.
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Document everything, and refuse to pay Physio if they’re the ones dropping the ball. If it ends up in court (hopefully they’ll submit properly in time) your documentation of their ineptitude will mean everything. I would suggest one more phone call to Physio’s billing department, ask for a supervisor, and explain that if they fail to properly submit the required paperwork, that you won’t be paying them.
Good luck.
I have been documenting everything- That’s how I know what dates things were supposedly submitted, etc. I’m not sure it’s enough to stand up in court. I feel like I’m gonna get screwed out of this whole thing. I tried calling their billing dept today but couldn’t get through. Instead, I tried another route and called the head at the Gunnison clinic. Hopefully that will get me somewhere. Oh, and yes, I’ve asked to speak to superiors before, but it sounds like it’s not something they do. “Oh, let me get you’re number and my superior will call you later today. ” Yeah, right.
Ultimately, I’d like to know more about what my rights are exactly- I can’t seem to find what I’m looking for on the Internet. Then, I can write them a detailed letter about my experience and outlining what I know my rights are as a patient.
The bad news is that Physio likely has a clause in their boilerplate that says you’re responsible for payment even if they’re incompetent and refuse to properly request payment from the insurance company. The good news is that that sort of nonsense tends to not hold up too well in the face of blatant ineptitude.
The best option in my eyes is for you to write an extremely detailed letter to Physio and have it sent via registered mail to the billing department and/or the corporate headquarters; email a copy as well so they have more time to try to fix the issue. At the same time ask Aetna for an extension for Physio (though it probably won’t help, there’s a chance they’ll do it) to get their act together. At the same time, ask Aetna to send you something stating that Physio’s initial submittal was incorrectly done, and that they have not received any updated ones. I can’t help you with what your legal rights do and do not entail as a patient.
I’m not a lawyer, I’ve just dealt with a lot of liability scenarios in my education and career. If it comes down to it, consult an attorney, etc. etc. etc.
Mike- Thanks for the advice. I was planning on writing a letter tomorrow. We’ll see where that gets me. As far as my insurance company goes, they are working on trying to change it from their end. I will find out more on Friday, probably, but it takes a few days for things to get processed.
I’m the furthest thing from a lawyer, but kudos to you for calling out this clinic on your blog. This is the digital age, and frankly every business whether small or large needs to accept that. If the clinic has a legitimate response, that isn’t canned from their lawyers, they’ll respond right here on your site.
for every 10 happy customers, there is 1 loud pissed off customer!
Thanks Bryan,
At this point I’m just hoping from some response from them at all. I’ve tried so hard, and I have gotten nowhere….
I cannot believe the gross negligence of PhysioTherapy. I called the Gunnison clinic yesterday- she sent a message to “corporate” and nothing happened. “I will call you today to check up on you to make sure somebody called”. That didn’t happen. Nor did anyone call from corporate. I called Gunnison again at 3:30 today and she blamed it on the fact her “computer was down”…. “someone should be calling you today or tomorrow”.
The problem with PhysioTherapy is that messages from individual clinics go off in cyberspace somewhere. Individual clinics don’t really have contact with any specific rep from Phyio’s corporate.
I called the CB clinic. Made the person there send out a message. I told her I felt like Physio’s behavior was ridiculously unprofessional…. I mean, really, how hard is it to send some copies?
Then, I tried to call “corporate” with a 1-866-925-2295. But, instead of saying PhysioTherapy, it answers with “Montgomery Associates”. WTF? It didn’t used to say that. Even more strange is there is no way to talk to a customer service rep. If you wait on the line, it sends you to a voicemail. You have some options to choose, like “If you were treated in Alabama, press 2” or something like that. But, no choice for Colorado. I called the Gunnison clinic and asked what was up w/ that and they had no clue.
Then, I looked up the number for Physio on the Internet- 1-866-786-8482. There, you can’t speak with anybody unless you know specific extensions. So, I left a message on the mass voicemail.
Oh my God, I can’t believe how hard it is to get a hold of these freaking people!!!! Any ideas? I’m seriously about to lose it.