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Written by Reed Tinsley, CPA | May 21, 2012
Back in April Aetna informed 130 physicians in Texas that they were being deselected from the Aetna network effective July 1st, 2012. Apparently this action is singular to Texas - it's a program that's national in scope. Over a year ago Aetna warned these deslected physicians of its concern about billing practices primarily involving levels 4 and 5 E&M codes. If you ever receive this type of warning, you must take action immediately. Set up a meeting with your provider representative to discuss and review any and all coding issues raised by the insurer.
This action by Aetna has impact beyond one major insurer dropping a physician - It most likely represents a “sea change”. Aetna’s confidence in eliminating physicians due to researched billing practices is a dramatic escalation of data-based medical management capability, i.e., third party administration with a definite directive to lower expense. Also, the decision to state “billing patterns” as a causative reason for winnowing physician ranks raises questions as to the undisclosed analysis of quality outcomes. Even more important, it also causes anxiety about how other managed care plans will react when it becomes public information that a physician is excluded from medical panel participation by Aetna. Will there be an industry move in aggregate to exclude that physician from other managed care panels?
I wonder which insurer is next to take this action against its physicians.
