Has Aetna Declared War on Out of Network Substance Abuse Providers?

Until recently did you consider Aetna as reliable a partner as Cigna and United Health Care?

Remember when Aetna paid your out of network residential and outpatient level substance abuse claims according to what was “reasonable and customary” in your particular zip code or geographic location? 

That all seems to have changed.  We recently did an audit of a dozen Aetna clients, all of whom had virtually identical insurance policies through Fortune 500 Companies (or in one case, one of most affluent U.S. cities).  Pre 2014, each of these policies would have paid 100% of the billed rate, after the client met his/her maximum out of pocket.  What we found was:

•         Payment was inconsistent with the benefits quoted by Aetna customer service representatives during very detailed benefit checks.

•         Claims for medically authorized treatment, same level of care, sequential days, could vary from 40% to 100%.

•         Claims for medically authorized treatment, various levels of care, sequential days, could vary from 40% to 100%.

•         Claims for medically authorized treatment for clients with identical policies from the same Fortune 500 company, varied from 25% to 100%.

A representative of Global Claim Services (“GCS”) that now reprices many claims for Aetna, emailed me the below basis for how Aetna now wants to pays for long term residential substance abuse treatment:

For determining a reasonable charge for outpatient claims, Aetna multiplies the facility’s estimated costs by 200%.  A facility’s costs are based upon the cost report information submitted by hospitals to the Center for Medicare and Medicaid services (CMS).  Using this information, CMS develops a cost-to-charge ratio specific to each hospital.  This ratio is applied to the claim charges to calculate the hospital’s costs for the services billed.  If a specific cost-to-charge ratio is not available, Aetna uses the state average outpatient cost-to-charge ratio, also developed by CMS.  Each line of the claim is also analyzed using industry standard coding methodology.  Reasonable charge is defined by 200% of the cost calculation.

There was no explanation as to why claims for residential inpatient services could be determined using costs of outpatient services provided by a hospital.

In some cases, GCS offered to “reconsider” the amount GCS told Aetna to pay.

We found that the reconsideration offers also varied considerably, depending on which GCS staff member was analyzing the claim.  For instance, GCS recently reconsidered eight claims for a single Aetna client, all billed sequentially.  GCS had originally advised Aetna to pay at about “40%” of billed.  The eight claims were “reconsidered” by six different GCS staff members.  The new percentage offered for Residential (RTC) claims varied from 66%-70.4%, depending on which GCS staff member was “reconsidering.”  The new percentage offered for each Partial Hospitalization (PHP) claim ranged from 65.86% to 71%.

If your recent experiences with Aetna are similar to those described above, please write to me at joanborsten@gmail.com.

NOTE:  As I was writing this article I got an email from Debbi Norton,  President of billing company UR1.  She advised:  “Just recently Aetna (like Blue Cross) has begun paying to the member/patient.”  I urged her, and each of you, to protect your income by having your clients complete paperwork that assigns his/her benefits to your treatment center, and also a power of attorney.  Both documents should be notarized.

This article solely reflects the opinions of the writer who is the co-founder and former owner of Malibu Beach Recovery Center.

BLUE CROSS CHECK UPDATE:  Assemblyman Richard Bloom needs more “impact statements” from California treatment centers that lost money when clients cashed checks sent to them by Blue Cross.  He also needs more “impact statements” from family and friends of clients who cashed the Blue Cross checks.  Please email joanborsten@gmail.com if you need forms.

Joan Borsten is the co-founder and former CEO of Malibu Beach Recovery Center as well as Senior Advisor at RiverMend Health.

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