Physicians fight Aetna over caps on out-of-network pay

The insurer has been the target of complaints that its policies regarding nonparticipating doctors are in violation of a lawsuit settlement, which the plan denies.

By Pamela Lewis Dolan, AMNews staff. Jan. 14, 2008.

Physicians in multiple states are crying foul at Aetna's declaration that it would cap the amount of reimbursement paid to out-of-network doctors at 125% of Medicare. They are also upset that Aetna informed patients through their explanation of benefits forms that they don't have to pay any bill a doctor might send to make up for costs and fees lost as a result of the insurer's cap.

Organized medicine is telling Aetna its move isn't just unfair -- it's also a violation of its settlement agreement with physicians as part of a class-action lawsuit that claimed health plans conspired to underpay physicians by downcoding and bundling physician claims. The settlement agreement says Aetna may not "disparage" nonparticipating physicians and that each EOB "shall indicate the amount for which the Physician may bill the Member and state 'Physician may bill you' such amount."

"The AMA cannot overemphasize its opposition to Aetna's policy of failing to adequately reimburse nonparticipating physicians, and strongly encourages Aetna to withdraw its policy of creating a ceiling tied to the Medicare fee schedule," American Medical Association Executive Vice President Michael D. Maves, MD, MBA, wrote in a Dec. 18, 2007, letter to Aetna. "Physicians must be immediately and correctly reimbursed for their billed charges."

In a few states, such as Pennsylvania, physicians recently have been upset over Aetna's declaration, in a letter to doctors, that the 125% is the "maximum state mandated rate." The Pennsylvania Medical Society said its state has no such rate.