Aetna OON facility payment reconsideration

[AGOG]

Is anyone experiencing a decrease in reconsideration payment from GCS (Aetna) for the facility(ASC) after April 1st, 2019?

[Nick D]

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.

[PMRNC]

For Aetna ERISA plans there is good cause for appeals for higher reimbursement using ERISA for OON.

[Nick D]

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?

[PMRNC]

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.

[Nick D]

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?

[Nick D]

Linda, I have a contact of "bertolinim@" for the CEO contact?

[PMRNC]

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.

[Nick D]

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?

[PMRNC]

Authorized Representative Form. The patient must sign it for you/office to appeal. Standard AOB is not valid for appealing ERISA claims.

[Nick D]

Thank you, Linda! Downloading the payer specific ARFs as we speak   

[PMRNC]

You don't have to have payer specific..You need only follow ERISA guidelines.

[Nick D]

Linda, can an ARF name the facility as the representative or does it have to be an individual?

[AGOG]

If I ask insurance company a SPD will they provide it to me on behalf of patients?

[Michele]

I believe the patient has to request it.