Recently it was discovered that Aetna had been incorrectly processing claims for Suffolk County Employees insurance plan (EMHP). Apparently, this plan has a $30 max benefit, yet up until recently claims were being reimbursed at Reasonable & Customary.
Some clinics verified benefits at the first of 2025 (and of course, documented the call as I teach with date, name of whom you spoke with, and a reference number for the call) but WERE NOT told about this max, however they are now getting recoupment letters. Others called but didn’t document, while some didn’t call at all.
Background Info
In my research I found out that this self-funded plan’s administration transitioned from Anthem (Empire BCBS) to Aetna on January 1, 2025. So clearly Aetna was providing incorrect benefits and/or incorrectly processing claims since they took over. (EMHP needs to KNOW this!)
In all cases before you even consider reimbursing, this should be appealed. I’ve created and shared a tool kit outlining my research, the various scenarios with template letters for appeals as well as strategies for moving forward. For the record, I have shared my materials with the Acupuncture Society of New York so ASNY members will have this information as well.
(Members – You will find my toolkit under the resources section Insurance Carrier Information >> Aetna, Click here to check it out!)
This situation outlines two important concepts that I consider EXTREMELY essential:
1. Verify Benefits
Verify Patients Benefits and share the results with the Patient, THEN have the patient also call their member line (never as busy as the provider line, staffed by higher level reps) and have them ALSO confirm their benefits. (If this had been done – the affected patients would IMMEDIATELY realize what the mistake made by their carrier and be proactive in helping resolve the issue.)
2. Be Clear
BE CLEAR with patients, that they are responsible for any charges not covered by their carrier, and BE PREPARED to bill patients when necessary. I’ve seen these types of issues over the years and I’m sure we will see them again. In ALL cases it was pro-active patients who complained, to their employer group, to their state’s Insurance Department, etc. that made the difference