Aetna Medicare supplement foreign claim denial

[33aa]

My wife and I were just on a Viking River cruise. Halfway through, I got sick and we had to leave the cruise to get me to an ER in Germany where I was admitted with Covid and pneumonia. Spent a total of three days and was discharged with a preliminary bill, paid by me, of $5,500. Submitted the claim to Aetna which just denied the claim because of "No procedure billing code" available. What in the world? German hospital, paid and submitted by me. Where exactly would this American insurance billing code come from? We did provide the hospital records so they know exactly what was provided and it was extremely straight forward. Anyone with experience on the best way to handle this?

 

Also interested in anyone's experience with TripMate which is supposed to cover trip interruption. We never made it back to finish the cruise because of fear of spreading it or getting re-infected. Have a statement from my long time Neuro to return  to the states ASAP. Submitted all receipts for lodging, meals, airline tickets, transport and medical including the letter from my Neuro. 

 

Should note this. Viking did not have any covid tests, or masks and would not have required us to shelter in place or quarantine and would have welcomed us back knowing full well I was a probable covid carrier and capable of infecting others. At least one other person was known to have gotten covid and there was an awful lot of coughing and sneezing going on. Just saying. But they were great on helping my wife find an ER, arrange cabs, hotel rooms and packing. So there is that too.

[Bo1953]

Sorry you took ill on your river cruise.

 

A hard lesson learned, especially if you did not read the coverage requirements for foreign travel.

 

Many of us, on Medicare, who do foreign travel do not rely on our Medicare/Medigap Plans to cover any illness/hospitalizations, we (almost always) purchase a third party insurance plan which is primary just in case we get sick while outside the U.S. with very few hoops to jump through other than being certain that all documentation/receipts are saved for submission to the insurer.

 

Pending your age, the price could be a concern, yet were it to be needed, price would not be the issue only reimbursement of the costs shelled out of pocket.

 

Have you called Aetna to confirm they do in fact require hospital billing codes for out of country billing for medical services or if there are other options to get reimbursed, it could be something very simple and easy to do?

 

Good luck and in health...

[33aa]

We did have TripMate as well and we have submitted the claims to them too. Based on what I've read, TripMate is notorious for claims denials so I'm not expecting much but we'll see.

 

Turns out that Aetna denied my claim because they determined it wasn't an emergency. So, I have history of accute covid (4 months in hospital in 2020 with two of those being in a coma), permanent lung damage (70% capacity), the local doctor insisted I be admitted and the diagnosis was covid and pneumonia and I was put on paxlovid and antibiotics but some claim processor at  Aetna decides it wasn't an emergency. Great. Oh, and was told by the claims processor there is no appeal even though I am looking directly at an appeal form. Unbelievable. 

Edited July 8 by 33aa

[Hlitner]

A tough situation.  The claims examiner looks at your claim, and lacking any coding (normal to any US-based claim) simply take the easy way out and rejects.  As one who spent a lifetime in the Medical Insurance/Government field, this kind of response (from the insurer) would drive me up a wall.  So, what to do?  My basic advice is to keep your cool, but do not give up trying to get the claim paid.  First step is to call Aetna (there should be a phone number on your card) and politely (always be polite) ask them for some guidance on what you can do to help expedite the claim.  If you get lucky, and happen to get a friendly customer service person, they should be able to give you advice and/or transfer you to their claims department.  

 

Aetna may ask you to contact the German hospital and have them "code" your services.  As a general rule, the European hospitals are not going to be helpful, and their billing department may say they do not have a clue.  Ask the to code each item with the appropriate "ICD10" code.  If they can also provide "CPT" codes this would be very helpful to Aetna.  I will emphasize that the "I" in "ICD" means "International" and the ICD10 coding system is recognized by the World Health Organization.  

 

If the German hospital refused to cooperate, this makes the situation difficult.  In Aetna's defense, without the codes (there are 10s of thousands of ICD codes) the Aetna folks do not have a way to price-out your claim.  They would either need to code it themselves (possible with a detailed medical record) or they may just continue to refuse your claim.  At that point, you can avail yourselves of the Medicare appeals procedures (I am not up to date on how this is currently handled).  With Medicare, you do have rights and if Aetna refuses to help you can push an appeal directly to Medicare.

 

None of this is fun.  Like you, DW and I have an Aetna Medicare Advantage Plan, which does say it covers foreign urgent/emergency care.  But, we also buy an annual Geoblue travel medical policy (which takes a primary position on claims) since we do not want to even think about dealing with Aetna on this kind of foreign claim. 

 

Hank

[GeezerCouple]

1 hour ago, 33aa said:

urns out that Aetna denied my claim because they determined it wasn't an emergency. So, I have history of accute covid (4 months in hospital in 2020 with two of those being in a coma), permanent lung damage (70% capacity), the local doctor insisted I be admitted and the diagnosis was covid and pneumonia and I was put on paxlovid and antibiotics but some claim processor at  Aetna decides it wasn't an emergency. Great. Oh, and was told by the claims processor there is no appeal even though I am looking directly at an appeal form. Unbelievable. 

 

Sorry you had this problem, and so glad you are recovered!

 

I'm not 100% sure when it is a MA (Medicare Advantage) plan.  But ordinarily, I'd suggest contacting your State Insurance Commissioner's Office, and include how they said there was no appeal.  Of course, they could deny that if it was just verbal.  Some of the calls may be recorded.  You can't get those, but the IC's office could IF it ever came to that.

And IF this company has had other "reports" like this and they've been found to be, er, negligent with claims handling, that might make it easier for you now. (??)

 

Or tell the insurer, once, that if they do not help you with the claim, you'll file a complaint with the IC's office.

Then do it, if still needed.

 

GC

[33aa]

Hank, thanks for the detailed reply. Very helpful info and guidance. We have a supplement rather than the Advantage plans. 

I'm guessing tripmate will also deny the claim since the primary, aetna supplement, denied it. This little ER side trip is looking to be, overall, a 10k+ hit. Sucks.

Coding aside. I vehemently disagree with the claims processor ignoring the local ER docs decision. I've asked my local Pulmonologist to write a statement about my damaged lungs and the risk to me with covid and pneumonia. I plan on appealing as far as I can. 

 

Truly thought this part of the claim was a slam dunk and that the problem would be solely with the trip interruption expenses.

 

Mark

Edited July 8 by 33aa

[GeezerCouple]

I probably should have added above (too late to edit now) that we also ALWAYS get 3rd party travel insurance.

 

For one thing, those companies are very familiar with how foreign health care and billing work.  They aren't trying to fit square records into round claims requirements, etc.

 

Working with claims for "foreign losses or medical care" is precisely what they do.  (Also claims for domestic travel if appropriate, but there's usually much less need for separate coverage for that.)

 

We get our travel insurance from www.TripInsuranceStore.com - as do many here.

They are a broker, but there is no extra cost.

CALL them so they can discuss what your specific needs would likely be.  (They don't try to upsell.)

 

Our policy is from Travel Insured, the actual insurance company, and they have always paid very promptly, with no nonsense.

 

GC

[jclinard]

My parents ran into a problem with a Canadian hospital not wanting to provide itemized bills so it would be covered with insurance.  They finally disputed the credit card billings for the hospital.

 

It was funny how quickly they decided to provide that information once it was that or not be paid.

[iamtrustworthy]

On 7/7/2024 at 6:14 PM, 33aa said:

My wife and I were just on a Viking River cruise. Halfway through, I got sick and we had to leave the cruise to get me to an ER in Germany where I was admitted with Covid and pneumonia. Spent a total of three days and was discharged with a preliminary bill, paid by me, of $5,500. Submitted the claim to Aetna which just denied the claim because of "No procedure billing code" available. What in the world? German hospital, paid and submitted by me. Where exactly would this American insurance billing code come from? We did provide the hospital records so they know exactly what was provided and it was extremely straight forward. Anyone with experience on the best way to handle this?

 

Also interested in anyone's experience with TripMate which is supposed to cover trip interruption. We never made it back to finish the cruise because of fear of spreading it or getting re-infected. Have a statement from my long time Neuro to return  to the states ASAP. Submitted all receipts for lodging, meals, airline tickets, transport and medical including the letter from my Neuro. 

 

Should note this. Viking did not have any covid tests, or masks and would not have required us to shelter in place or quarantine and would have welcomed us back knowing full well I was a probable covid carrier and capable of infecting others. At least one other person was known to have gotten covid and there was an awful lot of coughing and sneezing going on. Just saying. But they were great on helping my wife find an ER, arrange cabs, hotel rooms and packing. So there is that too.

Hi 33aa,

 

Call the insurance agent that sold you your Medigap plan and have them help you with your claim. They are obligated to help you with your claim because they earned and continue to earn a commission every time you pay your premium.

 

I've been an insurance agent since 1989. I help all my customers with their claims if they want my help. Even though I can sell Medigap plans, Life Insurance, Annuities and a lot of other plans, I don't sell them very often because my main focus is Travel Insurance.

 

Here's how a Medigap plan works outside the USA:

https://tripinsurancestore.com/medicare-does-not-cover-you-outside-the-usa/

 

Steve Dasseos

[33aa]

Steve,

Good suggestion and I already had done that. More or less useless. He just suggested I submit a claim for Foreign Travel expenses which I had already explained to him I had done and it was denied it claiming it wasn't an emergency. I did find an appeal form that states it is . It gives you the option of filling out the form or calling the CS number on the ID card (which would just take me back to the claims processor) or just send in more documentation via snail mail. 

 

My next course of action is to send the attached three letters, one from me, one from my Pulmonologist and one from my MS Neurologist. If that doesn't work I'll start escalating up the managerial chain. 

 

Thanks for the response and suggestion.

 

Mark

aetnadocletters.pdf

Markaetna.docx

Edited July 10 by 33aa