It appears that Aetna Healthcare, providing coverage for Spirit Aerosystems is now denying many members chiropractic care benefits. Although Aetna's benefit allows each member 26 visits a year, from July to July, many members are now paying full fee out of their own pockets.
Aetna has made numerous determinations denying treatment to Dopps patients. Patients are outraged and complaints are being made to the union.
We have seen a patient suffer injuries in an auto accident that have had their treatment denied as being maintenance care. Aetna's determination was that the patient didn't have a new injury, although it was clearly documented. They determined that treatment for his injuries from the day following the accident and each day thereafter, was maintenance care.
We had a patient that Aetna reviewed for medical necessity. They allowed her a time frame for care. She received treatment and recovered. She had a new injury and returned to the office. Aetna determined that her treatment was maintenance care.
We have a patient that lifts weights regularly. She comes in when she hurts herself. After Aetna's review, she now has to pay out of pocket. Aetna determined that her treatments were maintenance care.
We have seen reviews where Aetna misquotes dates of services for patients and requests information for dates that the patient was never seen. Even after bringing these details and mistakes to Aetna's attention and stating that we feel their must be some confusion on Aetna's behalf... That they are possibly confusing two patient files and should revist the review, asking for a fair and impartial review, Aetna upheld their determination.
New injuries should be a covered benefit, as long as a patient is within their 26 visit maximum per year. That's not case, as we are seeing.
Spirit Aerosystems has a self funded plan. What this means to a person that is covered by these plans, is that Aetna makes the final determination. It doesn't matter if it is fair, justified, or reasonable. Aetna is the final word. That is, unless someone choses to sue their employer utilizing their ERISA rights.
Spirit Aerosystems employees that are covered through Aetna are now paying more out of their own pockets for care. Many patients used to pay $20 each visit, but due to Aetna's new review and deny process, patients are left to cover the unpaid balances themselves. Luckily, Aetna has a very limited fee reimbursement, which means that many patients are paying as low as $32 for a visit. It's not great, when you should be paying $20, but it's better than $100. :)