It seems the Aetna payment schedule is an issue with a number of clinics.
The question is what do we do?
Mike Dodd had a suggestion to consolidate with allied health – is this
Tom Cutler mentioned the agents that underwrite plans – I will look into
This will get worse unless we stand up for ourselves and make some noise….
we need to help ourselves
From: [log in to unmask]
Date: 9/14/2021 12:25:14 PM
To: [log in to unmask]
Subject: Fw: Re: [OANDP-L] Aetna Payments
I posted a question on the List with regards to the Aetna issue….
When we submitted paperwork to become contracted with Aetna they gave us a
contract at 50% of Medicare. I declined to sign it and turned it down and
continued as out of network. In our area, Aetna is not a big player in our
small town. For us, if the pt has met the deductible, we submit the claim
but we don’t charge the excessive out of network rate. What we typically do
to be fair is adjust the claim after Aetna has paid to match Medicare’s rate
and don’t charge the above U&C price. We charge pt 20% co-insurance and
write off 20% to match their in-network benefits. This typically puts us
further ahead than getting Aetna to only reimburse at 50%. I think if I
remember correctly, as out of network, they pay 60% of Medicare’s rate, then
we charge patients 20% and write off 20%. On the flip side of this, if the
pt hasn’t met the deductible out of network but has in-network, they
typically will decide to go with another provider. So you may make more on
the patients that continue with you but you may also lose patients due to
the deductible. As far as I know, if you are out of network, you are not
bound by the Insurance and can make your own rules but whatever rule your
office has in place, it must be the same for all patients so you are not
providing favoritism. As a field, offices need to stop signing contracts at
these low rates and have more pride in our ability to do a better job than
DME companies. If the insurances start having lack of coverage for their
insured, I think that is the only way they would start offering more. I am
honest with patients and let them know I can’t provide a quality product and
thus optimal outcomes when Aetna wants me to work at 1/2 cost of other
insurances. I tell them I’m not solely about the money but I do need to be
able to keep the light bill paid. I also let them know all the insurances I
am contracted with in case they change their mind as to which provider they
Good Luck with this.
You just make dirt cheap legs.
Or, drop Aetna, to what HPO will say Thank you.
Doctors and other healthcare professionals are in the same boat. What they
did was to consolidate and then be able to negotiate a better rate of
reimbursement. That is what we should be thinking. Consolidation is the best
way forward in the future of healthcare. The big question is who do we
consolidate with. I think we need a meeting with all
Allied health professionals and start the conversation about how and who we
might do this with.
At this point Id be happy with 50% below Medicare. I have a denial after
delivery that the argument is it wasnt medically necessary. This was on a
patient that had revisions bilaterally and delivery was in February. Ive
asked for a Peer to peer, but as you said no one returns calls or answers
the phone. 6 months and no resolution…
Aetna has become trash since the first of the year.
At this point Aetna patients will be seen that are current patients.
Fortunately it isnt very common in my region.
David Seaman CPLP
My family is from an insurance background. Its interesting that I hear my
brother commenting about how they often advocate on behalf of a large client
to the insurance company.
I think that the insurance agents and agencies may be an untapped resource.
For example how would Aetna like for a bunch of chatty, well-connected
salespeople often with nothing exciting to discuss to tell customers that
Aetna reimbursement for prosthetics is hurting the most vulnerable amongst
An insurance agent is always on the lookout for some tidbit that nobody else
knows, which they can use as proof of their insider knowledge about the
insurance industry. And it makes the insurance association look good that
they can provide such information to their members.
Perhaps an article like, Your customers saying I have great insurance
doesnt actually mean that they have great coverage and then go on to say
that Aetna paying 100% of 50% less than Medicare will result in having all
of the qualified prosthetic folks refuse to serve Aetna subscribers.
From: Herb Shalant
Date: 9/14/2021 12:05:27 PM
To: [log in to unmask]
Subject: Re: [OANDP-L] Aetna Payments
If you signed a contract with them that’s still in force you have to accept
their fee schedule or refuse their patients.
Since most patients that have any insurance expect their insurance company
to pay for your services, don’t be surprised if you never hear from them
Good riddance, I say.
If enough people stop accepting their patients maybe they’ll reconsider
their abominable fee arrangement.
Aetna is probably the worse I’ve seen.
Herb Shalant, C.P.O.
White Plains, NY
On Tue, Sep 14, 2021 at 11:51 AM [log in to unmask] <[log in to unmask]>
We are getting new Aetna patients but recently the payment schedule is at
Medicare less 50% or more. There is no appealing it by phone because nobody
answers their phone lines and a paper appeal gets no acknowledgement.
We are at the point, as a single office clinic to refuse treatment to Aetna
patients because we are working at a loss on everyone single treatment for
the last 90 days.
Question – how do you manage your Aetna patients and make a profit or are
you going out of network?
Question, can we as a profession perhaps pay into a fund and get a lobbyist
to overturn this payment schedule? I have tried to call to discuss the
contractual fee schedule but with no affect. I have considered a third party
billing service but their % would actually make it worse.
Thanks awfully, I’m hopeful that some of you may have found a solution.
John Hattingh CP