-- National program alerts members when referred for out-of-network surgeries to raise awareness of costs and choices --
HARTFORD, Conn.--(BUSINESS WIRE)-- Aetna (NYSE: AET) is reaching out to members and their doctors to alert members when a referral for an outpatient surgical procedure may take them out of the Aetna network – and cost them much more money. An Aetna analysis has shown that half of members who received a referral to a surgery center did not know the referral would take them out of their health plan network. When those members were informed by Aetna and chose to stay in the network, the average medical bill was reduced by $5,000 per incident, which means members have much lower out-of-pocket costs.
A key advantage of having an Aetna benefit plan is the discount on the price of care provided by the carefully credentialed doctors, hospitals and other medical providers who participate in the Aetna network. In addition to these discounts, most Aetna health plans pay for a greater share of the cost when members receive care within the network.
“The intent of this national program is to help members avoid a surprisingly high medical bill. When Aetna can save a member thousands of dollars in out-of-pocket expenses, we truly are delivering substantial savings and real value,” said James D. Cross, M.D., Aetna’s head of National Medical Policy and Operations. “We want members to understand the real cost they face when they choose to have care outside of the Aetna network. At the same time, we are respecting the doctor-patient relationship by letting members know about quality, credentialed in-network medical facilities where their doctor is allowed to practice.”
Since August 2010, Aetna has found nearly 38,000 occasions nationwide when an in-network doctor referred an Aetna member to an out-of-network ambulatory surgery center. People often go to ambulatory surgery centers for out-patient surgical, scoping or other procedures. Remarkably, in nearly 60 percent of those cases, Aetna was able to tell the member and their doctor about a less expensive, in-network facility or hospital at which the member’s referring doctor had privileges.
The Aetna program is based on a precertification process that requires doctors to alert Aetna when they make a referral to an out-of-network free-standing ambulatory surgical facility for care. Based on certain guidelines, Aetna will follow up with the doctor and the member to ensure the member is aware that the referral will take them out of their network, which can often mean higher billed charges and lower benefit levels. In cases where members have no coverage for care outside of the network, except for emergencies, the referral goes through a separate review to determine if in-network care is available.
“People always have the choice in where they seek care,” said Paul Marchetti, Aetna’s head of National Care Management. “But we want to help our members avoid surprise bills. We encourage doctors and facilities, whether or not they participate in a health plan network, to join us in making sure patients ‘know before they go.’ All care providers should want to ensure the service they intend to perform is affordable for the patient, and we urge them to clearly and specifically share their prices with patients before they provide care.”
The letter sent to members includes information about Aetna’s online provider directory, DocFind, and refers members back to their health plan information, available on Aetna’s secure member website, Aetna Navigator, to ensure they know the details of their benefit plan’s coverage. On Aetna Navigator, members can also take advantage of Aetna’s on-line Member Payment Estimator tool, which is available to help members calculate a personalized estimate, specific to their benefit plan, for the cost of the care they plan to receive.
Aetna is one of the nation's leading diversified health care benefits companies, serving approximately 36.1 million people with information and resources to help them make better informed decisions about their health care. Aetna offers a broad range of traditional, voluntary and consumer-directed health insurance products and related services, including medical, pharmacy, dental, behavioral health, group life and disability plans, and medical management capabilities, Medicaid health care management services and health information technology services. Our customers include employer groups, individuals, college students, part-time and hourly workers, health plans, health care providers, governmental units, government-sponsored plans, labor groups and expatriates. For more information, see www.aetna.com.
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INDUSTRY KEYWORDS: Surgery Practice Management Health Hospitals Professional Services Insurance General Health Managed Care