Mark's complaint:
February 20, 2016

Insurance Company: Aetna
Coverage Type: Health Insurance

• PolicyHolder Service - Incompetent Employees
• Claim Handling - Unsatisfactory Settlement/Offer

I have a marketplace health plan through Innovation Health. Today I received my first 2016 explanation of benefits (EOB) for a covered service through a network provider but the EOB did not include a member, or negotiated, rate.

Thinking this was an oversight, or perhaps the claim was still not completed despite being noted as such, I called the member phone number on my card to discuss. That discussion led to a remarkably convoluted series of assertions:

* Claim that the only mental health services covered were kleptomania, pyromania, and some psychotic condition I don't remember. Argued over prolonged period until I read directly from the mental health section of the full coverage policy indicating general mental health services were covered, which was met with actual prolonged silence.

* During the above argument, I noted that nowhere were the limits on mental health to those 3 conditions disclosed. Agent erroneously claimed that was disclosed on the policy documents in my account (it wasn't because it wasn't true) and was available on the marketplace website before purchase (most definitely not true as the marketplace only provides links to the summary of benefits and gives no details about specific codes or procedures).

* Further countered assertion the condition wasn't covered by the fact that the amount of the service was shown as applying against our in-network deductible. Met with no response or explanation as to how it could not be a covered service yet would count against the deductible.

* Tack then turned to assert that there was no negotiated rate for mental health services and that's why the full billed amount was used. Countered in all my years of having health insurance, including with this very company for the last 2 years, I have never seen an in-network, covered service that didn't have a reduced contract rate. Provided the EOB for the exact same service performed in Sep, 2015, showing the negotiated rate was slightly over half the billed amount. The EOB was identical to this one, except for showing the negotiated rate paid to the provider.

* Asked for documentation to show that negotiated rates for mental health services were not part of this policy. While waiting, scanned through the full policy document and found absolutely no mention of the removal of contract rates. Agent was unable to provide any evidence or documentation that negotiated rates had been discontinued. I proffered that making such a change would be foolish as it would cause patients' deductibles to exhaust faster, leaving the insurer on the hook for paying more bills and those bills would be larger because there was no negotiated reduced rate. Again, silence, with yet another request to put me on hold to talk to a supervisor.

* Concluded the call with the agent stating no one available within their facility had access to information about negotiated rates. Then pushed the envelope on the previous claim to suggest it "could be" that all the new plans have no negotiated rates. For any service. Not just mental health. Agent said she reviewed a number of claims and "almost none of them" had an adjusted rate for the provider.

At this point, with no other contact options, had to conclude the call with no concrete information about how negotiated rates are being handled with my plan. I have no way to verify any of the following: whether my claim was processed properly, whether some covered in-network services have no negotiated rate, or whether *no* services have a negotiated rate.

I am unable to understand how not having a negotiated rate is even possible. If true, it would mean the insurer is willing to pay the full retail price of health care services for network providers, despite the fact that their value is elevated by having a large member pool. Further, most of the value of a high deductible plan would be realized by the patient paying the negotiated rate, rather than the full retail price providers set, which could already be paid without having insurance at all (and in most cases can, itself, be negotiated down with a cash price).

It is outrageous that a health-insurance policy can be marketed and sold without having to fully disclose all the details of the plan. In particular here, the elimination of reduced contract rates for in-network services is a complete break from industry standards and has a significant, major impact on my anticipated costs. Even the 2016 marketing for Innovation Health's plans contains reference to these rate reductions as a benefit to its members:

--- quote ---
How our network helps you save

A network is a group of health care providers. It includes doctors, specialists, dentists, hospitals and other facilities. These health care providers have a contract with us. As part of the contract, they provide services to our members at a lower rate.

This contract rate is usually much lower than what the doctor would charge if you weren’t an Innovation Health member. And the network doctor agrees to accept the contract rate as payment. You pay either your copay or toward your deductible.

So what does this all mean? It means you have access to the care you need at a lower price. And the difference in cost can be huge — for the same type of service or procedure.
--- end quote ---

Does that somehow suggest to anyone "Plans in 2016 will eliminate the negotiated contract rate"?

The impact of this underhanded practice on a high-deductible plan is huge. Using the negotiated rate as a benchmark, the only expectation for exhausting the deductible is an emergency hospital situation. Based on typical negotiated rates in the past, our family cost was expected to be roughly 2/3 of the deductible. By paying full retail cost as billed by the doctors? We will well exceed the deductible, adding an extra cost only anticipated for years with an emergency. Worst of all, this situation was never disclosed--nor has it been disclosed by evidence or documentation to this moment! I have only the word of a client rep who I had repeatedly caught in misinformation multiple times, and no one available to whom I can escalate. I have already submitted a complain to the VA state corporation commission, but I have no idea what legal ground I stand on.

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