Medical Billing Forum
Payments => Insurance Payments => : AGOG September 26, 2019, 02:08:31 PM
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Is anyone experiencing a decrease in reconsideration payment from GCS (Aetna) for the facility(ASC) after April 1st, 2019?
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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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For Aetna ERISA plans there is good cause for appeals for higher reimbursement using ERISA for OON.
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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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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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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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Linda, I have a contact of "bertolinim@" for the CEO contact?
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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.
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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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Authorized Representative Form. The patient must sign it for you/office to appeal. Standard AOB is not valid for appealing ERISA claims.
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Thank you, Linda! Downloading the payer specific ARFs as we speak :D
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You don't have to have payer specific..You need only follow ERISA guidelines.
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Linda, can an ARF name the facility as the representative or does it have to be an individual?
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If I ask insurance company a SPD will they provide it to me on behalf of patients?
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I believe the patient has to request it.
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Linda, can an ARF name the facility as the representative or does it have to be an individual?
Yes a patient can designate the facility as the ARF, so long as the appeal process is followed.
Patient usually has to provide the SPD. In some cases with large companies you can get lucky and find them online.