“Why would an assessment be covered for a leg but not for an elbow?” Charbonneau wondered. “Both were physical issues that needed help. I didn’t see a difference.
So Charbonneau, 60, of Arlington, an independent computer repairer, hired Aetna, one of the nation’s largest healthcare insurers with more than 20 million members and tens of billions in revenue l ‘last year. And it’s owned by CVS, one of the biggest companies in the country.
But getting Aetna to focus on her $ 450 problem proved futile.
After I got involved, Aetna investigated and, within hours, admitted that she had wrongly denied Charbonneau’s request and apologized.
Charbonneau’s persistence meant saving a relatively modest amount of money, little more than what he and his wife pay Aetna in monthly bonuses.
But what Charbonneau did also benefits others, as it forced Aetna to make a correction that will prevent them from being denied coverage in the same way.
“I’m not saying there was a big evil plot against me,” Charbonneau said after Aetna admitted her mistake. “It looks more like incompetence in a very large bureaucracy. Things are falling apart.
Aetna has over 45,000 employees who administer a dizzying array of health care plans.
Here is what happened :
Charbonneau, a longtime runner who has completed dozens of marathons, received treatment for his hamstrings after an assessment by a physiotherapist at Spaulding Rehabilitation Hospital in 2019.
Aetna says physiotherapist evaluations are covered and Charbonneau has not encountered any issues.
But when she returned two years later, her elbow was evaluated by an occupational therapist, which at the moment seemed unimportant. Charbonneau told me that Spaulding later told him that physiotherapists generally focus on the lower limbs (legs) while occupational therapists look after the upper limbs (arms).
A spokesperson for Spaulding told me that all physiotherapists and occupational therapists are trained in anatomy and that there is no clear distinction between therapists who assess and treat the arms and those who treat the legs. In practice, a physiotherapist is more likely to treat the lower extremities and an occupational therapist is more likely to treat the upper extremities, she said.
Occupational therapy focuses on a person’s ability to participate in daily tasks, including helping people recovering from injury regain skills such as writing, lifting objects, taking care of themselves. and support older people who are undergoing physical and cognitive changes.
Physiotherapy focuses on a person’s physical abilities to carry out activities incorporating strength, balance, and gross and fine motor coordination, Spaulding said.
Charbonneau’s elbow assessment was assigned to an occupational therapist certified as a hand therapist, the Spaulding spokesperson said. A certified hand therapist can be an occupational therapist or a physiotherapist, she said.
For Charbonneau, it does not matter whether he is examined by a physiotherapist or an occupational therapist. The diagnosis was correct both times and he was subsequently treated successfully for his hamstrings and elbow.
The problem, unbeknownst to Charbonneau at the time, was that Aetna did not include evaluations by occupational therapists as a covered procedure, due to an oversight rather than a matter of policy.
After being billed for the assessment, Charbonneau called Aetna’s customer service line, which is based in Hartford. Someone has promised to examine him and get back to him. Weeks passed. No one called.
Two more calls to Aetna followed, most recently on July 15. Once again, he was assured that his claim would be investigated. But, again, no reminder.
Then he called his wife’s employer, MITER Corp., through which the couple are insured. Late last month, a representative for MITER Corp., after conferring with Aetna, reported to Charbonneau that he was not covered.
The MITER representative explained to Charbonneau in an email that Aetna covered physiotherapy and occupational therapy and physiotherapy assessments, but not occupational therapy assessments.
“Therefore, the claim is handled properly,” and Charbonneau was not covered, the MITER representative said, based on what Aetna told him.
Once I contacted Aetna, the insurance giant quickly realized its oversight by not specifically including occupational therapy assessments among the benefits covered.
“Upon review, it was determined that the member’s request for an occupational therapy assessment had not been properly processed,” an Aetna spokesperson said in an email sent to me.
Go forward, Occupational therapy assessments will be specified as covered, the spokesperson wrote.
“We apologize to Mr. Charbonneau for any inconvenience this may have caused and have since restated the claim,” he said, adding that Charbonneau will now be covered for his elbow assessment.
What about the non-return of calls to Charbonneau?
“We apologize for not coming back to Mr. Charbonneau sooner,” replied the spokesperson. (In fact, it didn’t come back to him at all.) “A member of our customer service team contacted him today to let him know that the claim is being reprocessed.”
In fact, Charbonneau said, no one from Aetna at the time had contacted him by phone or email.
A happy ending? Yes, I guess, thanks to Charbonneau’s perseverance. But not all of us have the endurance of a long-distance runner.