Third Party Free, But Still Having to Fight For My Patients. UGH.

August 26, 2016

Dear Aetna Claims Department,

I do not have a provider agreement with you. Our agreement was severed in 2014 after a prolonged period of your company refusing to honor my request to terminate this relationship. I continue to see my patients who purchase coverage from you. They pay me at the time I provide their care, and then they submit claims to you for my services as an out of network provider. This is the second time you have sent me a check. I am concerned about the competency and accuracy of your claim processing. If this is happening to my patients and me, what does this mean for your entire client population?

The last time this happened, I returned the check you issued to me to you, and you then appropriately issued a check to the patient, who is your client with whom you have a contractual agreement. Sadly, I have no way to confirm the patient ever received the check from you. Often patients and physicians just give up during a prolonged, convoluted, and inaccurate claims process, which makes us wonder, is this accidental error or part of a business model?

This time, the patient is due $73.14 from you, but you sent the check to me. I am sympathetic to the patient that is due the money and harmed by the delay. So, I will write the patient a check and deposit the check you erroneously sent me. This time you have no way to know if I in turn forwarded the payment to your client, my patient. Fortunately, the patient-physician relationship is based on trust, personal communication, and competency. As a physician, I serve my patient first. That is my business model. The check will be sent to the patient today accompanied by a copy of this letter.

I will keep documentation of all this, because I do not trust that it will be accurately depicted on your end, and I need to protect my patient and my practice from you trying to claw back the payment in the future or accuse my practice of fraud- as the burden of proof falls on the physician now.

The amount of money misallocated by your company is something that may need to be investigated and improved upon. Perhaps, it is the insurance company that needs the quality/value rubric set forth by government’s MACRA, not the physician. Perhaps our patients would be better served if we worked together for the patient, not for the government.

We can and must do better.


Kristin S. Held, M.D.


2 thoughts on “Third Party Free, But Still Having to Fight For My Patients. UGH.

  1. Bravo Kris. A most appropriate response to a system in which the patient, for whom the system exists, is often at the bottom of the food chain. The Federal and medical bureaucrats have lost touch with the concept of the patient-physician relationship. It is not about the health and well being of the federal bureaucracy. It is not about the health and well being of the medical bureaucracy. It is all about the health and well being of the patient population

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