Dispute is over out of network doctors and the ability of doctors to bill patients for balances not covered by the HMO agreements...issue arises when in a network physician is not available for choice and patients have gone to an out of network doctor...Aetna has told patients to send the balance of of the doctors bills to them for payment..but if they pay less than the balance the patient is still caught in the middle...BD
Aetna and the American Medical Association are fighting about payments to doctors again, and patients across the nation are getting caught in between.
The dispute centers on how much Aetna pays out-of-network doctors in some instances and the right of those doctors to bill HMO members for charges the insurer doesn't pay.Millions of dollars are at stake, and physicians say Aetna is violating a provision of its 2003 nationwide settlement with doctors, which ended massive litigation over claim payment denials and delays. Aetna says it's trying to protect members from high charges. Staples, who has been talking and meeting with Aetna about settlement-related issues, said, "Aetna has been very cooperative in attempting to work out disputes … and I'm hopeful we'll work these out, too."
In those instances, Aetna HMOs, as of June 1, 2007, are reimbursing out-of-network providers 125 percent of what Medicare would have paid for the same services. A different formula is required in New Jersey. The 125 percent of Medicare, however, is less than what many doctors charge, and they often bill patients for the balance that insurance doesn't pay.
"Our goal is to keep patients out of this," said Aetna spokeswoman Susan G. Millerick. But some patients are in the thick of it, confused and refusing to pay the doctors.
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