So I’ve got something weird going on with my blood. The doctors keep taking samples and telling me my “numbers don’t make any sense”. I’m not overly-worried, but their final attempt to find out what is going on is to give me a colonoscopy (and I’m glad they left this as a ‘last resort’…). This was scheduled at my last visit a couple of months back, and the procedure day is now rapidly approaching.
In preparation for this (I assume) the service provider (my doctor) contacted my medical insurance provider (Aetna) to confirm I was still covered, and hadn’t changed or cancelled my insurance since the last time they checked a couple of months ago. Which I haven’t. But my doctor was told that I was “not an active subscriber” with Aetna. So they called me up to check my insurance details, which I confirmed were correct, and tried again. Same response: no active insurance.
So I check my bank to make sure my premiums (of $2K a month!) are still being taken out – just in case something had gone wrong with the direct debit – and they are. I checked Aetna’s member website and that confirmed I was a “subscriber in good standing:” (I love the way they refer to you as a ‘subscriber’ – like it’s a Netflix subscription or something where you’re paying for entertainment.) So I called Aetna up to ask them what was going on (my exact words: “So what’s the deal?”). They checked my details and confirmed that yes, everything was OK and there is no reason why I was being denied. In fact, they went as far as to say that they weren’t even showing a check for coverage that had been denied in their system (interesting!).
So I called the Dr.’s office back again, explained that I had just spoken to Aetna, and everything looked good, so could they please try again. They did. Again, “not an active subscriber”. I insist, again, that I am. They sigh, and tell me to get Aetna on the phone. So I do, and we have a three-way phone call between Aetna, the Dr.’s office and myself. The Dr.’s office provide Aetna with the information they are using to check my coverage, and Aetna confirm that is what they have in the system, and I confirm that is my correct information. Aetna get the Dr.’s Office to try again (this is now their 5th attempt…) and still it is coming back as denied. Aetna are puzzled, but suggest that maybe Availity have old information. Who’s Availity, you may ask – as I did.
Availity seem to be some form of ‘information broker’. They are a middle-man between medical providers and insurance companies. I guess to provide a single-point-of-contact (or ‘SPOC’ to use work terminology), to save everyone from having to talk to everyone else. Their website talks of a “transparent exchange of information”, but to me, the end-customer, this is all very far from transparent. And if Availity said I didn’t have any coverage, but Aetna said that they didn’t even have a record of a check being made, exactly what information are they holding, and when is it being refreshed? Because I have been covered by Aetna since January 2023 – 18 months ago.
The long of it is that Aetna provide me with medical coverage, and my Dr.’s office wants to provide me with medical services covered by Aetna, but for god knows what reason, Availity are saying “No!”. This should be extremely concerning for every patient whose doctor or insurance company uses Availity. Or at least to doctors, who may be missing out on potential earnings when they are told that a patient is not covered by insurance, when they actually are.
I went to Availity’s website (availity.com) and tried to find a way of contacting them – to work out why they were saying I did not have active insurance, and to get my information corrected if it is wrong. But all of their contact mechanisms require you to enter your customer number with them. Which, obviously, I don’t have. I’m just the poor schmuck at the end of the food chain dying because they told my doctor he can’t look up my arse and find out what’s wrong with me.
I found their Facebook page and sent them a direct message via that, but when they responded, they just directed me to the other mechanisms listed on their website.
So I went back to the website and completed the ‘new provider’ query form, knowing that that had to get in front of someone’s actual eyeballs, but their response was (and I quote): “Availity cannot speak with patients directly because we cannot verify your identity to comply with HIPAA requirements regarding PHI.” But…but…this is my PHI (Protected Health Information) – and if you can’t verify my identity with me, something is very, very wrong (although the inability to verify a patient’s identity would certainly explain a lot!).
At this point my options are to get Aetna to lodge a complaint with Availity – but why would they, as any denial of coverage actually benefits Aetna – or get the Dr.’s office to do it, So I’ll pursue that avenue and see where it leads. And if I don’t get a valid resolution from them, I’ll be sure to send some photos of my colonoscopy to Availity’s main office. Let’s see if that elicits a response!
P.S. If you want to learn more about Availity, take a quick trip through https://availity.pissedconsumer.com/review.html where Availity have an average rating of 1.2/5, and a 97% disapproval rate. See, it’s not just me!
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