Author Topic: Aetna OON facility payment reconsideration  (Read 5123 times)

AGOG

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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

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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.
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PMRNC

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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
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Nick D

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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?
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PMRNC

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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.
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Re: Aetna OON facility payment reconsideration
« Reply #4 on: September 30, 2019, 12:47:01 PM »

Nick D

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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?
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Nick D

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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?
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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

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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?
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PMRNC

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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
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Re: Aetna OON facility payment reconsideration
« Reply #9 on: October 01, 2019, 01:51:52 PM »

Nick D

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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
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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
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Nick D

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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?
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AGOG

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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

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Re: Aetna OON facility payment reconsideration
« Reply #14 on: October 11, 2019, 10:34:28 AM »
I believe the patient has to request it.
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Re: Aetna OON facility payment reconsideration
« Reply #14 on: October 11, 2019, 10:34:28 AM »