August 2002
Volume 66 |
Number 8
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PRACTICE MANAGEMENT
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| Understanding
the New Aetna |
Karin Bierstein, J.D.
Assistant Director of Governmental Affairs (Regulatory)
When John Rowe, M.D., took over as CEO of Aetna U.S. Healthcare
in 2000, the insurance company began to transform itself into
a new entity. Changes in top management quickly led to a new policy
of communication and cooperation with medical specialty societies.
Jeffrey Livovich, M.D., an anesthesiologist in Aetna's medical
policy group, contacted ASA members L. Charles Novak, M.D., and
Rodney L. Trytko, M.D., whom he had known in a prior position.
Soon afterward, with the strong support of his supervisor James
Cross, M.D., the national director of Aetna's Medical Policy and
Transplant unit, Dr. Livovich began working directly with the
ASA Washington Office and Alexander A. Hannenberg, M.D., who had
succeeded Dr. Novak as chair of the Committee on Economics.
Late last year, Aetna local contractors sent letters to their
participating anesthesiologists announcing a new set of payment
policies for anesthesia services effective April 1, 2002. These
policies were intended to bring consistency and rationality to
Aetna payments to anesthesiologists across the country and across
health plans. Some of the changes did not reflect a solid understanding
of long-established anesthesia payment principles, however, and
ASA and Aetna began to discuss modifications.
Changes to the Original Aetna Policy
The first result of our discussions was Aetna's decision to rescind
a policy that would have denied payment for monitored anesthesia
care provided to ASA physical status 1 or 2 patients in the ambulatory
setting, which Dr. Hannenberg described more fully in his May
2002 NEWSLETTER article, "Private Payer Perils."
Next was Aetna's agreement to pay for invasive monitoring lines
without applying the "multiple procedure reductions"
generally used when a physician performs several surgical procedures
at the same session. Aetna thus chose to follow the Medicare policy
that ASA had secured through litigation and a quick settlement
agreement with the Health Care Financing Administration (now the
Centers for Medicare & Medicaid Services [CMS]) in 1995.
In June, Aetna reversed itself on the important issue of covering
nerve blocks placed for the management of postoperative pain on
the day of surgery. Aetna will follow the well-established policy
that was most recently described in the October 2001 issue of
CPT Assistant®: If these procedures "are performed in conjunction
with general anesthesia to provide postoperative analgesia, they
are separate and distinct procedures and are reported in addition
to the anesthesia code."
Aetna also has informed us that it will recognize the principle
stated on page "x" of the 2002 ASA Relative Value Guide:
"Any procedure around the head, neck or shoulder girdle,
requiring field avoidance, or any procedure requiring a position
other than supine or lithotomy, has a minimum Basic Value of 5.0
regardless of any lesser basic value assigned to such a procedure
in the body of the Relative Value Guide."
Most recently, Aetna confirmed that it has updated the obstetrical
anesthesia codes to match those in the 2002 RVG.
The Significance of Our Relationship
There are of course some areas on which ASA and Aetna still
do not agree such as the additional base units associated with
patients of extreme age (99100) and with emergency conditions
(99140). These are far less important than our relationship with
Aetna through Dr. Cross, who as national medical policy director
is the person who makes changes happen, and through Dr. Livovich,
the anesthesiologist who fully understands our views. Together
we have achieved a remarkable number of policy improvements in
a short period of time, and we are confident that Aetna will continue
to listen to our concerns. A recent example is the assurance that,
unlike United Health Care, Aetna does not intend to use the Medicare
medical direction modifiers so as to cut fees for teaching anesthesiologists.
Both parties are aware that the many policy changes that Aetna
is implementing (not just in anesthesia) have been accompanied
by some internal communication problems. Some of the local offices
are understandably confused. In another display of their good
faith, Drs. Cross and Livovich have permitted us to distribute
the current national Aetna anesthesia policies to our members
on request. You may download a copy at < www.ASAhq.org/Washington/aetnapolicies.doc
>. Aetna plans to post its reimbursement and coverage policies
on its own Web site within the year. This is an ongoing exercise,
and we will make copies of updates available.
Aetna also will distribute the policies internally and educate
the network and provider representatives in its local markets.
Despite anything that readers may have heard or read recently
to the contrary, Aetna is working hard with ASA to put in place
reasonable and fair anesthesia payment policies and practices.
We believe that we have, in turn, shown Aetna that ASA is a principled
and honest representative of the specialty. We would be delighted
if other payers follow this model of cooperation.
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Source Materials:
• Hannenberg A. Private payer perils. ASA Newsl.
2002; 66(5):24-25.
• Anesthesia and Postoperative Pain Management.
CPT Assistant 2001; 11(10):9. (Published by the American
Medical Association < www.ama-assn.org/cpt/online
> .
• Medicare Program; Revisions to Payment Policies
Under the Physician Fee Schedule for Calendar Year
2003; Proposed Rule. 67 Fed.Reg. 125: 43846-44013,
June 28, 2002 < cms.hhs.gov/physicians/pfs/default.asp
>.
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