Aetna, AMA fight over out-of-network payments

Aetna and the American Medical Association are locked in a dispute over payments to out of network physicians--and whether consumers should bear the burden of any additional costs that the health plan refuses to pay. The core of the dispute is over what should happen when an Aetna HMO member ends up getting care from non-network physicians involuntarily, usually in emergencies situations or with hospital-based procedures where the patient doesn't get a chance to choose supporting doctors (such as anesthesiologists used for surgery).

Typically, when Aetna pays for out-of-network physician services under these conditions, it offers them 125 percent of what Medicare would have paid for those services. However, that's often less than the physician would have charged--so physicians end up billing the patient for the balance. Aetna, for its part, is instructing its HMO members who involuntarily use out-of-network physicians not to pay that additional bill, and instead, to send the bill back to the health plan. Aetna then attempts to resolve the difference itself in negotiations with the doctor.

The AMA objects to this policy, however. It calls the 125 percent of Medicare rate "arbitrary," as it doesn't account for practice variation. What's more, it claims that this approach breaches a 2003 settlement of a national case doctors brought against it over claims payment denials and delays in payment. And they contend that the doctors have every right to balance-bill the patient. Aetna, says that since the patient involuntarily used the out-of-network physician, it's treating the bills as though they were in-network and handling them accordingly.

To learn more about the dispute:
- read this Hartford Courant piece

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