Beginning in early March, acupuncturists—primarily on the East Coast—began reporting recoupments involving patients with Medicare Advantage coverage. Below is a summary of the known facts at this time:
- Scope of Impact
- These recoupments are affecting both in-network and out-of-network acupuncturists.
- Plan Type Involved
- The issue appears to involve patients enrolled in Medicare Advantage PPO ESA (Extended Service Area) plans. These are specialized group retiree plans that allow members to see any licensed provider, with the same in-network cost-sharing applied to both in-network and out-of-network services. Providers are required to accept the plan’s terms and submit claims to Aetna.
In practical terms, these plans are designed to allow patients to seek care from any provider—regardless of network status—while maintaining consistent copays.
Based on available plan documentation, these ESA plans were intended to reimburse Medicare-allowable rates for both in-network and out-of-network services (consistent with network agreement terms).
However, it appears that:
- In-network providers were paid contracted rates
- Out-of-network providers were paid billed charges, rather than Medicare-allowable amounts
- Recoupment Activity
- Providers are now receiving Explanations of Benefits (EOBs) indicating that Aetna intends to recoup these payments.
At this time, many providers report that they have not received formal demand letters outlining:
- The reason for the recoupment
- Repayment options
- Instructions for submitting a reconsideration or appeal
- Geographic Reach
- While these plans are limited to certain employer-sponsored retiree groups, affected providers have been identified in multiple states, including New Jersey, New York, Washington, Minnesota, and California.
- Aetna Response and Current Status
- Communication with Aetna has indicated that the company considers this issue urgent and is actively reviewing the situation.
The claims processing issue has been corrected as of January 1 and are now being processed appropriately.
My experience has been that carriers do NOT start recoupment efforts UNTIL providers are notified with a formal letter of demand. HOWEVER what is happening here is clearly not typical and as such providers may want to hold off treating these patients until we have clear confirmation that a formal letter WILL be issued with instructions regarding reimbursement.