Author Topic: Aetna OON facility payment reconsideration  (Read 3416 times)

AGOG

  • Newbie
  • *
  • Posts: 7
Aetna OON facility payment reconsideration
« on: September 26, 2019, 02:08:31 PM »
Is anyone experiencing a decrease in reconsideration payment from GCS (Aetna) for the facility(ASC) after April 1st, 2019?

Nick D

  • Newbie
  • *
  • Posts: 39
Re: Aetna OON facility payment reconsideration
« Reply #1 on: September 26, 2019, 04:31:26 PM »
After 4/1/19 they dropped the "standard" policies to about 30% of billed as the max after negotiations. The change didn't effect the other policy types.
OON Facilities Billing Manager

PMRNC

  • Hero Member
  • *****
  • Posts: 4562
    • One Stop Resources & Networking for Medical Billers
Re: Aetna OON facility payment reconsideration
« Reply #2 on: September 28, 2019, 12:41:36 PM »
For Aetna ERISA plans there is good cause for appeals for higher reimbursement using ERISA for OON.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

Nick D

  • Newbie
  • *
  • Posts: 39
Re: Aetna OON facility payment reconsideration
« Reply #3 on: September 30, 2019, 10:50:20 AM »
For Aetna ERISA plans there is good cause for appeals for higher reimbursement using ERISA for OON.

Have you personally had success utilizing ERISA for Aetna low payers?
OON Facilities Billing Manager

PMRNC

  • Hero Member
  • *****
  • Posts: 4562
    • One Stop Resources & Networking for Medical Billers
Re: Aetna OON facility payment reconsideration
« Reply #4 on: September 30, 2019, 12:47:01 PM »
For OON they reduce the fee to U&C which is patient responsibility, we then get help of patient and file appeal. Yes I've not lost one appeal yet for full reimbursement. Mostly I appeal the higher surgical fees. I do Mental health for group that is non par with Aetna. Since I have other pediatric clients, many times we see full billed fee after appeal.  Pre-billing we usually get a precertificaion done for surgical claims and then we let patient know our fee is $XX more and proceed to tell them of our appeal process and they are very cooperative.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

Nick D

  • Newbie
  • *
  • Posts: 39
Re: Aetna OON facility payment reconsideration
« Reply #5 on: October 01, 2019, 09:07:40 AM »
For OON they reduce the fee to U&C which is patient responsibility, we then get help of patient and file appeal. Yes I've not lost one appeal yet for full reimbursement. Mostly I appeal the higher surgical fees. I do Mental health for group that is non par with Aetna. Since I have other pediatric clients, many times we see full billed fee after appeal.  Pre-billing we usually get a precertificaion done for surgical claims and then we let patient know our fee is $XX more and proceed to tell them of our appeal process and they are very cooperative.

Can you give me the fax/contact you send your Aetna ERISA appeals to?
OON Facilities Billing Manager

Nick D

  • Newbie
  • *
  • Posts: 39
Re: Aetna OON facility payment reconsideration
« Reply #6 on: October 01, 2019, 12:42:02 PM »
Linda, I have a contact of "bertolinim@" for the CEO contact?
OON Facilities Billing Manager

PMRNC

  • Hero Member
  • *****
  • Posts: 4562
    • One Stop Resources & Networking for Medical Billers
Re: Aetna OON facility payment reconsideration
« Reply #7 on: October 01, 2019, 01:17:29 PM »
I have done MANY ERISA appeals and not ONE has ever be sent to a CEO. With ERISA appeals it is of the utmost importance to follow the exact appeal process in the patient's SPD. Some plans such as union plans have a board of trustee's who you must send the appeal to, if you send appeal to CEO of the payer it's just getting kicked over to them and they would have a basis for denial if the appeal process is not followed. A patient's SPD will spell out exactly where to send appeal and who to send it to that is Second step in the process. First step is the patient must sign a valid ARF because a standard AOB is insufficient.

Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

Nick D

  • Newbie
  • *
  • Posts: 39
Re: Aetna OON facility payment reconsideration
« Reply #8 on: October 01, 2019, 01:35:50 PM »
I have done MANY ERISA appeals and not ONE has ever be sent to a CEO. With ERISA appeals it is of the utmost importance to follow the exact appeal process in the patient's SPD. Some plans such as union plans have a board of trustee's who you must send the appeal to, if you send appeal to CEO of the payer it's just getting kicked over to them and they would have a basis for denial if the appeal process is not followed. A patient's SPD will spell out exactly where to send appeal and who to send it to that is Second step in the process. First step is the patient must sign a valid ARF because a standard AOB is insufficient.

Please define the ARF acronym?
OON Facilities Billing Manager

PMRNC

  • Hero Member
  • *****
  • Posts: 4562
    • One Stop Resources & Networking for Medical Billers
Re: Aetna OON facility payment reconsideration
« Reply #9 on: October 01, 2019, 01:51:52 PM »
Authorized Representative Form. The patient must sign it for you/office to appeal. Standard AOB is not valid for appealing ERISA claims.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

Nick D

  • Newbie
  • *
  • Posts: 39
Re: Aetna OON facility payment reconsideration
« Reply #10 on: October 01, 2019, 04:04:21 PM »
Thank you, Linda! Downloading the payer specific ARFs as we speak   :D
OON Facilities Billing Manager

PMRNC

  • Hero Member
  • *****
  • Posts: 4562
    • One Stop Resources & Networking for Medical Billers
Re: Aetna OON facility payment reconsideration
« Reply #11 on: October 01, 2019, 08:07:16 PM »
You don't have to have payer specific..You need only follow ERISA guidelines.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

Nick D

  • Newbie
  • *
  • Posts: 39
Re: Aetna OON facility payment reconsideration
« Reply #12 on: October 08, 2019, 04:02:33 PM »
Linda, can an ARF name the facility as the representative or does it have to be an individual?
OON Facilities Billing Manager

AGOG

  • Newbie
  • *
  • Posts: 7
Re: Aetna OON facility payment reconsideration
« Reply #13 on: October 11, 2019, 09:47:46 AM »
If I ask insurance company a SPD will they provide it to me on behalf of patients?


Michele

  • Global Moderator
  • Hero Member
  • *****
  • Posts: 5927
    • Solutions Medical Billing
Re: Aetna OON facility payment reconsideration
« Reply #14 on: October 11, 2019, 10:34:28 AM »
I believe the patient has to request it.
Sign Up for our FREE Medical Billing Newsletter
Get a 10% discount on Medical Billing Products by using Coupon Code: 10OFF
http://www.solutions-medical-billing.com

Medical Billing Forum

Re: Aetna OON facility payment reconsideration
« Reply #14 on: October 11, 2019, 10:34:28 AM »