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Aetna OON facility payment reconsideration

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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:

--- Quote from: PMRNC 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.

--- End quote ---

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.

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