Oxford Health Plans and Aetna have sent letters to New Jersey members and providers announcing restrictions on reimbursement for out-of-network services that may force ASCs to go entirely in-network, according to Jeffrey Shanton, director of business management for Journal Square Surgical Center in Jersey City, N.J.
In a letter to members, Oxford announced that when an employer renews its plan with the payor, "the amended benefit will provide reimbursement for all covered services delivered by non-participating providers, based on a percentage of published rates allowed by Medicare. This revised percentage will be 140 percent of the standard Medicare rates."
"They are effectively circumventing the commercial arbitration process, as MAXIMUS (which operates the Program for Independent Claims Payment Arbitration of the N.J. Department of Banking and Insurance (DOBI)) arbitrates according to policy payment guidelines," Mr. Shanton says. "So if the policy says 140 percent of Medicare, that is what MAXIMUS would go by for payment, not 80th percentile of Ingenix. Unless you would have a tremendous, I mean explosive increase in volume, you would never be able to survive" on this rate.
Aetna has sent a similar letter to providers announcing that beginning Oct. 1, the new OON services benefit "will be based on a percentage of the Medicare rate for the service, rather than the current benefit based on 'reasonable' or 'prevailing' charges." A percentage was not specified.
"There is nothing in DOBI regulations that prevents them from doing this, or placing restrictive caps on plans," Mr. Shanton says. "Thus even if DOBI were on our side, they would be obligated to allow the policies to go through.
Aetna also instructed providers that effective Oct. 1, all providers not directly contracted with Aetna who provide OON services for Aetna members should follow Medicare billing guidelines when submitting claims.
Mr. Shanton said these latest efforts by payors to essentially push providers in-network is further indication of the dire situation facing ASCs in the state.
"The only way to combat this is to get legislation-laws passed," he says. "That is why A2882 is so important. It would instruct DOBI [to prohibit] plans that have caps, restrictions or anything else for OON providers."
These attempts by payors to reduce or place restrictions/caps on OON services bring another major issue back into the spotlight for Mr. Shanton.
"Without the choice of OON, you have a monopoly, with the carriers holding all the cards," he says. "Down the road you will see the in-network contracts dip lower and lower. How can any healthcare provider negotiate with them? They have no leverage. Oxford holds all the cards — take it or leave it."