Thursday, July 07, 2011

Preparing for Aetna's Multiple Procedure Reductions Policy

As Aetna moves to apply multiple procedure reductions to certain therapy procedures for dates of service beginning November 14, it is imperative that physical therapists read and understand their Aetna contracts. If possible, seek legal counsel for recommendations of potential areas to negotiate or to look for clauses that may be problematic. Working with legal counsel will enable physical therapists to better understand terms and provisions within the agreement.

Comments

what procedures are they currently looking to subject to the MPPR and what % of reduction?

Posted by Nancy Mullins on 7/8/2011 2:57 PM
I highly recommend that therapists seek legal advice and not just sit back and think they have to accept this. Aetna may not have complied with the Notice requirements in your contract by merely posting a vaguely worded notice in their electronic newsletter. Your provider agreement may also require such amendments to be signed by both parties. The policy did not state whether they were applying the policy to non-Medicare products or just Medicare products. Depending on what your previously agreed upon Aetna Market Fee Schedule was, this may be a substantial change that would not qualify as a mere "fee schedule update." Private insurers do not have to adopt Medicare payment policies. Whether they can apply this policy to your contract without you agreeing and signing an amendment depends on the terms of YOUR provider contract. It is worth checking out. Gwen Simons, Esq, PT,OCS, FAAOMPT Simons & Associates Law, P.A. gwen@simonsassociateslaw.com (This post should not be construed as legal advice or a solicitation, only advice that you seek legal advice from your own attorney!)

Posted by Gwen Simons on 7/8/2011 6:26 PM
another problem I see with this, is that Aetna typically only allows 4 units per visit, which Medicare does not have that restriction, they also dont pay the same. I think this is a situation where Aetna is trying to apply this procedure to solely benefit them. It's not like they increase their fee schedule when the Medicare fee schedule increases.

Posted by Dano Napoli on 7/18/2011 10:14 AM
I am a chiropractor who received a similar notice - except for 2 differing details. Effective October 1st, 2013, the procedure with highest RVU is allowed at 100% - other therapies performed by same provider group will be allowed at 50%

Posted by Dr J on 7/5/2013 2:24 PM
Aetna uses a rental network for our claims since we are not directly contracted with Aetna. Our rental network is a per diem rate - Aetna is applying the MPPR to our per diem contract and we cannot get them to understand that this is wrong. Do you have any literature that we can send them to support this?

Posted by Kerry Scudder on 6/25/2014 5:43 PM

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