Aetna 25 visit max

I’ve discussed Aetna before…their covering only specific conditions, etc.  but I’ve never talked about how “unlimited visit” policies work. For starters, there are hurdles to jump to get “unlimited visits.”  Typically with Aetna, after a patient has 25 visits of a particular kind (even when the patient has unlimited visits), they will stop paying and request records and conduct a medical review.  I was dumbfounded this week when I was told this on a patient who had just started coming in.  Although we saw this patient back in 2005, he hadn’t been back in until now, 2012; 7 years.  I was convinced that this was a mistake.  On the 2nd phonecall, where the same information was repeated, I had to wonder if this was a correct recital of their policy – this was the patients 25th OVERALL acupuncture visit from 2005-2012…they said that it didn’t matter that the patient hadn’t been in for 7 years, after 25 visits they conduct a review, period.  I, of course, argued that this was absurd since it had been 7 YEARS but they assured me this was the policy.  As I knew this policy to be, benefits are annual (or benefit year) but in this case, calendar year.  If the patient hit 25 visits in 2012, I would be expecting this review.  But to add up all visits ever had…even those that span NEW PATIENT timeframes, because by definition he was a new patient, they still wanted this info.  I’ve submitted it and will see how this goes, I just think it is absolutely ridiculous…I think the same policy would apply if the patient sees another acupuncturists…..it’s acupuncture visits TOTAL that they will be looking at.  So, the moral of the story is that “unlimited visits” is something you will always have to fight for, after 25 visits, and sometimes sooner than you might think.