(C) Illustration by Mark Matcho

Either knowingly and maliciously or unwittingly and incompetently--it is hard to know which is worse--Aetna's health insurance ends up scamming members out of contractual benefits. I can only imagine this ends up aggregating to tens of millions of dollars nationally. I have also seen Blue Shield of California do this exact same thing and would bet many other health insurance companies follow the same procedure.

Here's how it works: Assume Memorial Sloan-Kettering is "in network" (which it is for me.) But following treatment, when you get your bills  they aren't always just from "Memorial Sloan-Kettering" they are often from a bevy of different group names within the hospital, for instance one might be "Memorial Cardiopulmonary Group" (which is a bill I recently received). These various names are all part of the originating hospital, in this case Memorial Sloan-Kettering and are all definitively "in network" but for billing purposes (so the hospital can correctly track expenses) they come from different groups and tax identification numbers. BUT what Aetna does is process the claim as "out of network" the first time they receive it. Therein lies the scam. By processing the claim as out of network, they force the member to pay a greater percentage of the claim and end up paying less themselves. To have the problem corrected, the member must then call in to the customer service number. But the elderly, less educated (don't understand their benefits), rich (who don't look carefully at bills) or just less anal folks out there most likely never catch these mistakes and up and getting royally screwed. 

Being young and fastidious, I read every single Explanation of Benefits ("EOB" in industry parlance) I receive and catch hopefully 100% of theses "errors." I'd estimate in the past 24 months I've caught somewhere between 150 and 300 such "errors." Now remember, I know to look for this issue and I make the time to call customer service. So Aetna I am calling you out. This is either an administrative error of gross negligence or it's a knowing and deceitful con hidden behind the sham of a technical glitch in your  conveniently Byzantine systems. My bet is that it is malicious. You deny and mark claims as "out of network" knowing full well that only X% of customers will call in to have these mistakes corrected. You then pocket the difference. To make matters worse, there is no systematic way for customers like me to prevent this from happening over and over again. I feel like Bill Murray in Groundhog Day every time I read an EOB and it shows" Memorial Sloan XXXX Group" or "Northwestern Memorial XXXX Group" which should both clearly be in network but you have decided to make them out of network. There's just no way you can be so incompetent as to not know what's in network and what's out of network and 100% of the time assume it's out of network without some level of maliciousness. I just had my bill for "Memorial Cardiopulmonary Group" fixed. The supervisor I spoke to said there's no way for me to proactively prevent this from happening...probably because it is convenient for Aetna's bottom line.

The sad truth is I know there's going to be dozens more like it in the future and there' nothing I can do as the little guy but call to have them individually corrected. Oh, yeah and perhaps write about your scam on my blog.