Question: My provider wants to become in network with Aetna. The reimbursement with Aetna is awful. We have a client with Aetna primary, Medicare secondary. Previously we didn't have to calculate the OTAF because we were non-par provider. My question is, once we calculate OTAF, will Medicare consider up to their allowable, or just up to what Aetna will allow.
Ex: k0011 we bill 5000, Aetna allows 2000 Medicare allowable is 3700
Aetna pays 80% after the clients 500 ded. so they pay 1200 Medicare would have paid 2960
Will the calculation be 2000-1200 = 800, and that is what Medicare will pay 800.00???