Author Topic: PENDED CLAIM - AETNA  (Read 1507 times)

zakassam

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PENDED CLAIM - AETNA
« on: August 03, 2013, 12:22:29 PM »
Aetna has pended one of our claims due to additional information needed from referring provider and patient. They needed clinicals for the patients and they mailed a questionnaire to the patient to have them fill out and sent back. They said if this information is not received in a timely manner they will deny the claim. Is this really something they can do? We sent in all the clinicals and are trying to contact the patients, but can they really just deny the claim for that? We are an out of network provider.

RichardP

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Re: PENDED CLAIM - AETNA
« Reply #1 on: August 03, 2013, 12:57:49 PM »
Is this really something they can do?

Short answer = yes.

It's called rationed health care.  We have all manner of denials, even when the claim is good.  We've come to the conclusion that is the insurance carriers' (including Medicare) way of evening out their expenditures / payouts from month to month or quarter to quarter.  Too much money paid out this quarter on claims?  Send a whole bunch back for "further information", or outright deny the claim.  That pushes payment of the claims, if the billers are tenacious enough to follow up and demand payment because the claim is good, out a few months and into a new quarter.

It's all part of the unecessary cost of doing busines in health care.

PMRNC

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Re: PENDED CLAIM - AETNA
« Reply #2 on: August 04, 2013, 12:16:46 PM »
Quote
Aetna has pended one of our claims due to additional information needed from referring provider and patient

The carrier may need other information in regards to other coverage, it could be a few things. It might not be related to the additional information you sent in at all. Yes they can do this. When they pended the claim they notified you and the claimaint. I would contact the patient and let them know the claim is unpaid, and they should either pay the bill in full and request payment from their carrier (you said you were non par).

Quote
We've come to the conclusion that is the insurance carriers' (including Medicare) way of evening out their expenditures / payouts from month to month or quarter to quarter.  Too much money paid out this quarter on claims?  Send a whole bunch back for "further information", or outright deny the claim.

It's easy to say that and believe it too especially if you have never worked on the other side. Insurance carriers lose POINT ratings, no they do not purposely hold up claims.  I think us entitled American's FORGET what insurance was created for.. those companies are in the business of RISK management. If they are not responsible for payment of any claim they have the right to investigate further to determine liability and risk.   
Linda Walker
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www.billerswebsite.com

RichardP

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Re: PENDED CLAIM - AETNA
« Reply #3 on: August 04, 2013, 12:50:01 PM »
.. those companies are in the business of RISK management. If they are not responsible for payment of any claim they have the right to investigate further to determine liability and risk.

I agree.  And I should have made that clear in my original post, as the default reason for why a claim is pended.

shanbull

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Re: PENDED CLAIM - AETNA
« Reply #4 on: September 27, 2013, 04:39:42 PM »
Yes they will deny it after a specific amount of time without hearing from the patient, but they will generally reconsider the charges upon receipt of response from the patient.

DMK

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Re: PENDED CLAIM - AETNA
« Reply #5 on: September 27, 2013, 04:43:30 PM »
I get these "pended" claim notifications from Blue Cross and Blue Shield fairly regularly.  As soon as I get it I send the patient a letter informing them that they need to take care of it or they will have to pay the bill.  I always include a copy of the notification AND the phone number and their ID# so that they're prepared to take care of it.  Response is usually fairly good.

If the patient doesn't take care of it, and the insurance denies the claim due to their non-response, they get the bill.