Ann & Natalie’s Compliance Corner
Welcome back to Ann & Natalie’s Compliance Corner! This month, we discuss Aetna’s recent announcement of its revised set of “principles” aimed at identifying specific behaviors and business actions that govern its corporate interactions with physicians and other health care professionals. Missed last month’s report on the Department of Health and Human Services Office of the Inspector General’s (OIG) updates to the Provider Self Disclosure Protocol? Click here.
On May 28, 2008, Aetna, Inc., a Hartford, Connecticut based health care benefits company, introduced its Guiding Principles for Physician Relations (Principles), an initiative that defines the organization’s continued commitment to building the best possible relationships with the medical community. It also reaffirms Aetna’s continued commitment to working collaboratively to improve the quality of health care, according to a company press release.
“True health care reform will come from public, private and government sectors addressing issues together. We have worked hard to establish a level of trust and respect with health care professionals. And we want to build on that trust and continue to be a high-integrity business partner with the medical community,” said Troyen Brennan, M.D., Aetna’s chief medical officer. “These Guiding Principles clearly demonstrate, in writing, that we are serious about making it even easier to do business with us and moving forward with the medical community to ensure patients have the highest quality, safest and most cost-effective care.”
Aetna said that it recognizes that Americans are concerned with health care access, quality and affordability, and explained that the Principles reflect Aetna’s historically proactive approach to working cooperatively with the medical community.
Aetna released the Principles on the eve of the June 2, 2008 expiration of a settlement agreement between Aetna and hundreds of thousands of providers who, in 2000, filed a lawsuit against the nation’s largest for-profit insurers, including Aetna. The multidistrict litigation brought by the providers alleged that the managed care companies conspired together to underpay the physicians in violation of the Racketeer Influenced and Corrupt Organizations Act (RICO).
Aetna was the first health plan to reach a settlement agreement with the physicians, which it voluntarily extended one-year past its original expiration date, the press release said.
“Aetna has made significant progress in its relationships with physicians by changing past practices that were not consistently transparent and respectful of providers,” said Robert W. Seligson, executive vice president and CEO of the North Carolina Medical Society, and president of the Physicians Advocacy Institute (PAI), a nationwide not-for-profit organization that advances the interests of the physician community. “Much of that success has resulted from the company’s constructive dialogue with physicians and putting its words into action. We obviously will not always agree. However, Aetna’s commitment to remain true to the spirit of the settlement agreement ensures our conversations will be candid and productive and this will set the stage for quicker resolution of any future issues. Aetna’s voluntary continuation of the business practices from the settlement is a model for other health plans.”
Aetna says that the changes it has made as part of the settlement agreement are embedded in the company’s business model and are consistent with the way the company wants to continue working with physicians. Aetna highlighted specific areas of the Principles that it believes demonstrate its commitment to working cooperatively with physicians, such as its decision to allow physicians to terminate from its network 90 days after receipt of notice with no need to show cause, and its continued allowance of claims submissions up to 120 days after the service was provided.
Aetna further committed to continue a number of transparency reforms, such as disclosing all precertification requirements in a timely manner, and not using all-product or “gag” clauses in contracts. Aetna said it will continue to use the new definition of “medical necessity,” to provide transparent information on its claim check logic, and to work with providers to ensure consistency in bundling and other claim policies.
In addition, Aetna will continue working with the Physicians Advocacy Institute to help physicians better understand how various health plan initiatives, such as pay for performance and physician ratings, impact the day-to-day care that physicians provide their patients. The company also said that it will maintain a Physician Advisory Board, comprised of independent practicing physicians who will provide advice on issues of importance to doctors and make recommendations as appropriate with regard to Aetna’s business practices and policies.
To access the Aetna Principles, please visit: www.aetna.com/provider/medical/join_med/advantages_med/principles.html
Disclaimer: The content of Compliance Corner is for general informational purposes only and should not be interpreted as compliance guidance or advice. Consult your compliance advisor or attorney for compliance or legal advice on specific issues related to your practice or compliance program.
