NCDOI Affirms Aetna Underpayment of Non-Participating Providers

January 20th, 2008

The NC Department of Insurance (NCDOI) has responded unfavorably to a complaint filed jointly by the North Carolina Medical Society (NCMS), the North Carolina College of Emergency Physicians and Wake Emergency Physicians.

The complaint, filed on October 30, 2007, asserted that Aetna had violated North Carolina’s prudent layperson statute (NCMS Section 58-3-190) by imposing greater cost sharing on patients treated by emergency non-participating physicians than would have been imposed had the patient visited a participating emergency physician.

Aetna has adopted a nationwide policy of paying hospital-based non-participating physicians only 125% of Medicare. NCDOI and Aetna dismissed this argument, and instead defended Aetna’s policy and suggested that patients were not penalized by imposition of this policy, which will result in increased balance bills.”The carrier should have every opportunity to negotiate the service charge while protecting the member from penalty when contracted providers are not reasonably available or accessible,” Ted A. Hamby, NCDOI Deputy Commissioner, stated. View the complaint and the NCDOI/Aetna response.

The NCMS has stated it is reviewing its options in addressing this “extremely negative response.”

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