Emergency care doctors, insurer Aetna’s tiff impacts subscribers
Aetna is urging about 200,000 policyholders to call the insurer if they get a bill for treatment from emergency care physicians at Allegheny Health Network hospitals, saying the doctors have begun charging patients higher rates in the midst of contract negotiations.
The doctors group, Emergency Medicine Physicians, says it is billing patients because Aetna is paying far less for treatment than is customary when insurers and doctors have no contract.
“It’s unfortunate that the insurance company has decided to use this as a negotiating tactic,” said Dr. David Scott, chief administrative officer for the group based in Canton, Ohio.
Aetna’s letters tell policyholders that the emergency doctors are not in the insurer’s network. All other Allegheny Health doctors are in Aetna’s network, according to a health network spokesman.
The letters, sent in the past week, went to all members who have seen an Allegheny Health Network doctor in the past 12 months, whether it was an emergency physician or not, said Aetna spokesman Walt Cherniak.
Allegheny Health Network includes Allegheny General Hospital in the North Side, West Penn in Bloomfield, Allegheny Valley Hospital in Natrona Heights, Canonsburg General, Forbes in Monroeville, Jefferson Regional Medical Center in Jefferson Hills and Saint Vincent Health Center in Erie.
The doctors’ group billed more than 800 patients starting in September for the difference between what the insurer pays for treatment and what the doctors group charges, Cherniak said.
The insurer and doctors group began negotiations in April 2014 after a joint venture formed by Emergency Medicine Physicians and Allegheny Health Network took over emergency care at Allegheny Health Network’s hospitals and an urgent-care center. The venture’s formation nullified previous contracts between Aetna and the doctors.
The insurer and doctors group have not reached an agreement on the rates Aetna pays for in-network care, both sides said, so the doctors group started billing patients for the full amount it charges for treatment. In-network rates usually are much lower than out-of-network rates and doctors’ direct charges.
State and federal laws prevent insurers from forcing patients to pay out-of-network rates for emergency medical care. But the laws don’t prevent medical providers from charging patients the balance if an insurer does not pay contracted rates.
Aetna says it is paying the doctors group its standard rates for emergency care doctors who are not part of its network. The doctors group says Aetna is paying much less than insurers normally pay when there is no contract.
“The whole situation illustrates why we need stronger protections at the state level,” said Erin Ninehouser, policy director for patient advocate group Pennsylvania Health Access Network.
Several states have passed laws to prevent or limit balance billing, often by forcing insurers and providers to work out differences before going to patients.
Pennsylvania Insurance Commissioner Teresa Miller held a hearing this month on balance billing, saying consumers should not be stuck with bills when hospitals are in their networks but doctors at the hospitals are not.
Pennsylvania has a law prohibiting balance billing for emergency care in some cases, according to the Insurance Department, but the protection does not apply to employer-based health plans, the most common type of insurance.
Aetna encourages its members to go to the closest emergency room when needed, but requests that they contact Aetna immediately if they get a bill for services from an Allegheny Health Network emergency room physician.
Wes Venteicher is a staff writer for Trib Total Media. He can be reached at 412-380-5676 or [email protected].