AMA Disputes Aetna Policy For Reimbursing Some Out-of-Network Provider

Main Category: Primary Care / General Practice
Also Included In: Medicare / Medicaid / SCHIP;  Public Health
Article Date: 14 Jan 2008 - 11:00 PDT

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American Medical Association officials have said they believe Aetna's policy for reimbursing some out-of-network providers violates the insurer's 2003 nationwide settlement with physicians over claim payments and denials, the Hartford Courant reports. Aetna on June 1, 2007, began enforcing its policy of reimbursing out-of-network providers for 125% of what Medicare would have paid for the same services in cases where HMO patients were unable to seek care from an in-network provider.

Aetna's policy regarding involuntary use of out-of-network providers -- such as during emergencies or in surgery that involves a lack of patient choice over physicians or anesthesiologists -- is to tell members that they are not responsible for any balance sent to them by physicians. Aetna sends HMO members an "explanation of benefits" that shows what it paid the physician and tells members to send the company balances billed by doctors. Aetna then attempts to resolve the situation with the out-of-network provider. The insurer says that because the care received is involuntary, it is treated as if it were in-network, which would not allow the physician to balance-bill the patient.

The insurer noted that the policy is not new, but before June 1, it had not been consistently enforced. Aetna said that before June 2007, it received 18,000 bills per month from members and physicians, compared with an average of 7,600 per month after the new policy took effect. The insurer said some physicians change three to four times what Medicare would pay.

AMA says the policy violates the 2003 settlement because the company does not state on explanation of benefits forms that out-of-network physicians have a right to balance-bill members. AMA CEO Michael Mayes in a recent letter to Aetna Chief Medical Officer Troyen Brennan said, "This policy fails to recognize each physician has different practice costs as reflected by their billed charges," adding, "It is simply arbitrary and capricious for Aetna to deem 125% of Medicare to be a fair payment across the board." Mayes and Brennan are scheduled to meet to discuss the issue next month.

In the end, it "isn't clear how much money consumers will still be on the hook for," and some patients end up "in the thick of it, confused and refusing to pay the doctors," according to the Courant (Levick, Hartford Courant, 1/11).

Reprinted with kind permission from http://www.kaisernetwork.org. You can view the entire Kaiser Daily Health Policy Report, search the archives, or sign up for email delivery at http://www.kaisernetwork.org/dailyreports/healthpolicy. The Kaiser Daily Health Policy Report is published for kaisernetwork.org, a free service of The Henry J. Kaiser Family Foundation© 2005 Advisory Board Company and Kaiser Family Foundation. All rights reserved.

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