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Further Aetna Updates

by NYSCA Insurance Committee | 10/31/2018 2:19:41 PM

The following information has been received from Aetna to assist in your transition to the new program.

Contracting

Aetna has extended the time frame by which you must contract with them to remain in network to 11/1/18. Remember, your participating status with Optum/ACN relative to Aetna's insureds expires on 12/31/18. Aetna has advised us that they will continue to contract with doctors after 11/1/18; however, Aetna must provide 30 days advance notice to their insureds/your patients if you fail to contract with them in a timely manner. If you do not sign a contract directly with Aetna you will be considered out of network and your patients will be advised of the change in your network status.

Q: I already contracted with Aetna. Why did I receive another letter inviting me to contract with them?
Aetna has reached out to current participating providers rendering care to Aetna insureds again to advise that they have extended the timeframe to contract until 11/1/18. If you are concerned about the status of your contract with Aetna, reach out to Aetna via email at [email protected] to check on your status.

Q: I did not receive confirmation of my request for an application on Aetna.com, and still have not received a contract or request for more information from Aetna. What should I do?
Aetna has recognized that confirmation of your request was not part of the initial process. As noted in their updated recruitment letters, you should now bypass requesting an application via the 'application request form on Aetna.com. You should send any inquires via email to [email protected]. You can also inquire as to the status of your contract by email at the same address.

Aetna is also reaching out to specific doctors proactively in order to ensure there is no disruption in patient care. As always, save copies of your correspondences and follow up in a timely manner.

Q: I am not comfortable signing a contract without knowing what the reimbursement is. Is the fee schedule available yet? Is Aetna still reimbursing lower than Medicare for certain plans?
Federal antitrust laws prohibit and prevent the NYSCA from advising you to sign or avoid signing a contract. Federal antitrust law views doctors of chiropractic as highly intelligent professionals capable of making important personal and professional decisions independently, separately and on your own. The Association can provide you with factual information that may help you reach your personal decision, but legally the Association cannot make this decision for you or tell you whether to sign or not sign a particular contract or agreement.

We have confirmed with Aetna that the full fee schedule is available. If you are currently in the contracting process, email Aetna at [email protected] to receive a copy of the fee schedule. Remember, Aetna fee schedules are confidential documents and are to be treated as such (which is one reason why the NYSCA cannot post them). It is our understanding that these are considered market fee schedules, and do not vary by specialty or provider discipline.

Utilization Management

Western NY
Although you must still contract directly with Aetna by 11/1, many of you were not required to authorize care through Optum, or your Optum contract may have excluded Aetna due to the sparse insured population. Aetna will be sending us a list of the involved counties; however, you can also inquire about your specific county by emailing [email protected]

Aetna has provided a notice specific to Western NY. This notice indicates a 1/1/19 start date for Utilization Management (again through NIA) and lists a series of live webinars that you can attend. Similar to the rest of NY, your patient population for which you must obtain authorization appears to exclude the self-funded groups and is limited to the remaining HMO/PPO population and Aetna's Medicare plans. You can log in to RadMD.com and enter your patient's name, date of birth (similar to checking eligibility - simply follow the instruction on the screen) to determine whether authorization is required.

Q: I was a tier one provider under Optum. Do I have to submit documentation to NIA?
It is our understanding that the contracts with Optum remain in effect until 12/31/18. Optum 'Tier One' providers are typically excluded from submitting clinical information for payment purposes.

The NYSCA cannot advise you as to whether or not you should submit clinical information to NIA for services rendered after 9/1/18 and before 1/1/19; however, it is always best to err on the side of caution. The NYSCA Insurance Committee has suggested that Aetna incorporate the current Optum tiers during this transition to reduce the administrative burden for all parties concerned. Aetna will be working with NIA to 'gold card' providers (Aetna's tiering process).

Q: I checked RadMD.com and it indicated that authorization was not required. Now my claim has been denied. What is the next step?
Although you may have been advised to appeal the claim denial, Aetna has recognized that both the RadMD portal may have provided inaccurate information, and the authorization information may not have been uploaded into Aetna's claim processing system prior to your submitting your claim.

Note that Aetna has been responsive to our feedback that the RadMD site had some functionality issues relative to authorization requirements (that appears to have been corrected), and is proactively reprocessing claims that may have been inappropriately denied. We recommend calling Aetna first, rather than taking the time to write an appeal. Feedback from providers who have followed this simple step has been excellent, as their claims are being reprocessed (presumptively with correct applicable payment forthcoming).

Webinars and additional information relative to NIA's utilization management process.

Please note the following:

1) As previously noted, NIA posted a link to a recorded webinar on 10/8. That link is: You may also review a PowerPoint presentation, which is available on the NIA website.

2) NIA has compiled two documents (Physical Medicine Tip Sheet and Physical Medicine Services Checklist) to assist you in facilitating the authorization of medically necessary services through NIA.

3) Aetna has advised us that additional Webinars can be scheduled as needed. Per our discussion with Aetna, you do not have to be a provider in Western NY to attend the November webinars posted in the NIA notice above. We suggest starting with either the recorded webinar or PowerPoint presentations linked above to expedite your participation in the UM process.

Q: Why is Aetna requiring utilization review for Medicare Advantage patients? CMT is the only covered service and the copayments are typically higher than the reimbursement?
We have discussed this with Aetna and reviewed the many advantages of not requiring utilization management of this patient population. Please continue to submit your clinical documentation to NIA as you may need the EOB to bill any secondary carrier for non-covered services (exams, modalities, procedures, etc). Aetna is reviewing this internally and will be reporting back to us. They are also reviewing the EOB to ensure that non-covered services are flagged as 'patient responsibility' to ensure your office and patients understand their financial obligations.

Please note that Aetna has been responsive to many of your concerns and wants to hear from you if you are experiencing difficulties with this transition, whether contracting, utilization review, or claims processing. Do not put your reimbursement at risk by not authorizing your care through NIA; do not put your contract at risk by failing to respond in a timely manner. Please also advise NYSCA if you require additional assistance or to share information with other NYSCA members.

Your dedicated Insurance Committee

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