03/17/2022
Issues with Aetna Payments-Out of Network Rates for 1199 Retirees
I am currently having a problem with payments from Aetna (NY) at the out of network rates. I have never had a problem with Aetna but it seems that as of January 1, 2022 all Aetna patients who were with 1199 and have since retired, these claims are being paid at the in network rate. I have never been in network and when I call them they do confirm that I am out of Network but can't give me an explanation as to why the payments are being based on in network rates. I called the credentialing department first who confirmed that I am out of network and then they told me to call claims which I did but to my surprise no one could help me figure out the problem. The plan that these patients have is the Aetna VO3 PPO medicare plan. Please advise . Thank you.
You will need to appeal each of these denials with the Aetna Medicare Advantage Plan that were paid in error with the in-network rate of reimbursement. After review of all the Aetna Medicare Advantage Plan provider panels, you are not listed on any of them. Since credentialing was able to confirm that your practice is OON, but customer service was not able to adjust the claim, the appeals form would be the only way to get these claims adjusted, to pay at the correct rate since we cannot involve a network relations representative for an OON provider.
Based on the volume of incorrectly processed claims for 1199SEIU retirees, if this continues, this will need to be escalated to the complaint board or to the NYS insurance board for a formal complaint against Aetna for processing errors.