Aetna program aims to increase in-network referrals
A new national program from Aetna that seeks to lower the number of out-of-network referrals for outpatient surgical procedures will actively alert both members and their doctors if they are leaving the insurer’s network for care and work to shift the referral to an in-network provider.
The aim, according to the company, is to alert members who may not know their referral is out of network and thus may cost them more money. Studies by the insurer have shown that half of all members who received a surgery referral did not know it would take them out of the network and potentially expose them to greater out-of-pocket expense. Aetna added that shifting the care to in-network providers provides an average savings of $5,000 per incident.
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“The intent of this national program is to help members avoid a surprisingly high medical bill,” said James D. Cross, MD, Aetna’s head of National Medical Policy and Operations, in a press release. “We want members to understand the real cost they face when they choose to have care outside of the Aetna network.”
Over more than 20 months of collecting data on outpatient surgery referrals, Aetna identified more than 38,000 cases where members received a referral from an in-network doctor to an out-of-network ambulatory surgery center. In nearly 60 percent of these cases, Aetna identified less expensive, in-network facilities or hospitals where the referring doctor had privileges.
The program hinges on a precertification process that requires doctors to notify the insurer when they make an out-of-network referral to a freestanding ambulatory surgical center. Using a set of internal guidelines, Aetna may then contact the doctor and the member to alert them that the referral is out of network and may incur higher charges and lower benefit levels.
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“People always have the choice in where they seek care,” said Paul Marchetti, Aetna’s head of National Care Management, in a prepared statement. “But we want to help our members avoid surprise bills.”
To help members understand and manage this aspect of their healthcare, Aetna directs members to a number of its online tools, including DocFind –the company’s online provider directory – and Aetna Navigator, which provides the details of their plan’s coverage, as well as a payment estimator tool that helps members calculate the total cost of the care for which they were referred.
