Attention Aetna Patients or Potential Aetna Patients in VIRGINIA

By October 13, 2011Blog, What's New

On December 1, 2011, Aetna will change the way chiropractic benefits are managed in Virginia.  As of that date, all Aetna chiropractic coverage will be handled through a third-party managed care organization called American Specialty Health Network (ASHN). Currently, ASHN’s involvement has applied only to Aetna’s POS plan and the HMO.

Based on our experience with ASHN managing coverage with Aetna and other insurers, this expansion of the program will not benefit you as the patient in any way.    If you are currently a  PPO member, as a result of this change you will experience a reduction in your chiropractic benefit.  One way that insurance companies that utilize third-party managed care organizations impact your care, is to do so by limiting utilization (i.e. the number of visits they will authorize for your condition). They do this by requiring providers like us to fill out standardized forms which do not demonstrate the entire clinical picture and limit our ability to communicate your entire condition.  And as a result, they don’t approve visits by stating that medical necessity has not been demonstrated.  Another way, is to limit the number of procedures that providers can perform and subsequently bill for.  This will be the case with this Aetna change.

Just as importantly, while your insurance company may tell you that you have 100% coverage, we have seen the vast majority of these plans cause the patient to actually pay significantly more, if not all of, the total cost of care. What you may not realize is that when you pay your co-pay, the insurance company reduces the amount they pay by the amount of the co-pay. Under ASHN, co-pays routinely exceed the amount paid by the insurance company so there is an elimination of expense for both the insurance company and the third-party managed care organization.

Here is how this works:

  • You may have a $40.00 co-pay for chiropractic services.
  • The allowed amount paid by the insurance company for two services provided by Sport and Spine Rehab would be a total of $26.00. Allowed amount is the reduced amount that doctors at Sport and Spine Rehab are paid by the insurance company, not what we bill.
  • Because your co-pay exceeds the allowable amount paid by the insurance company, the insurance company pays nothing, while you, the patient, have paid everything. You have paid for the insurance premium to have the coverage, AND you have paid for the full services provided by doctors like us.
  • The insurance company will tell you that you have 100% coverage, but in fact, you have no coverage at all.
  • Why then would you or your employer pay for a chiropractic benefit as part of your insurance premium when in fact you have no coverage at all?

In the physician world, this is called an “illusory benefit”. Most ASHN plans that are doing business in the Commonwealth of Virginia have this exact scenario. Of course your co-pays vary by employer negotiated coverage and it remains to be seen how this will play out with the PPO but by limiting the number of codes that can be allowed, you can expect similar outcomes in the PPO coverage.

Lastly, for patients with health savings accounts (HSA’s) we have seen very specific examples of the insurance company collecting funds from the patient’s HSA, and subsequently, the third party administrator actually denying the care, and thus not paying the provider, for services rendered, yet the funds had already been withdrawn. In these specific examples, we are working with patients and their physicians to bring this to the attention of state lawmakers and agencies.

We believe it is important as a consumer, that you are aware of these policies and how they may impact your access to covered care.  This is the time of the year when many of us as employers and as consumers are making those important decisions about health care coverage for the new year and this could be an important consideration. Should you agree that these types of coverage changes are a concern and could impact you, you may feel inclined to voice your opinion about them.   We are offering some options below.

  • You can contact your employer’s Human Resources (HR) Department and let them know that you are not happy with this change of benefit. They may not be aware of how this is impacting your benefit.  Your company and/or you are paying for benefits, however these utilization restrictions will allow greater insurance company profitability at the expense of your health.  And reduced access to treatment in the long run costs employers by increased time off and reduced productivity.
  • You can contact Aetna directly and have them explain what changes are in store for your policy with regard to chiropractic coverage (1-800-US-AETNA; 7:00 AM – 7:00 PM EST).
  • And if you are not happy with the coming changes, let Aetna know. http://member.aetna.com/Member_Public/contactUs.jsp or write to the address shown on the back of your Aetna card.

Thank you for your understanding about this.  Again we feel it is very important for you as a consumer and or as an employer to be aware of these changes.

It has been our pleasure to serve you as one of your health care providers and we sincerely hope that we may continue to provide you the level of care you deserve.  For us as providers, these changes require us to decide whether we can continue to remain in network as a participating provider for Aetna due to the treatment limitations imposed on us, and thus further limiting your access to the quality care you deserve.  We sincerely hope to be able to continue our relationship with you and serve your healthcare needs.

To your best health,

The Staff at Sport and Spine Rehab

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