Aetna Deselecting 130 Texas Physicians

Aetna has notified 130 Texas physicians it will terminate them from its networks on July 1, TMA's Payment Advocacy Department has learned. Aetna says it told the physicians a year ago it was concerned about their billing patterns. Evaluation and management (E&M) codes were the only ones Aetna examined, and its concern involves primarily levels 4 and 5 E&M codes.

Aetna says in letters to the deselected physicians that its data shows their billing and coding practices caused them to be more costly than their peers. TMA secured legal protections in Texas that require Aetna to tell physicians why they are deselected.

TMA has developed a white paper on physicians' basic rights and responsibilities in network terminations. It is not specific to Aetna; any physician deselected by any health plan network can use it.

The 130 Texas physicians are among doctors nationwide that Aetna is removing from its networks. The action has sparked outrage by physicians. One physician posted the following comment on TMA's Blogged Arteries: "How does Aetna have the arrogance to admit that these 130 docs cost them too much from their bottom line? What about the patients they're leaving in the lurch? Anybody care about them?"

Nationally, some of the outrage is directed toward Aetna Chief Executive Officer Mark Bertolini. The Hartford Courant reported that one New Jersey physician, John Tedeschi, MD, posted a video on YouTube in which he said he tried contacting Mr. Bertolini, but was told he doesn’t speak to physicians.

He says in the video that he is amazed a physician "trying to save lives and help individuals, is controlled by an individual that made $8 million last year. And he’s not a physician. He's directing health care. He's some great entrepreneur that's going to change the world in technology and he doesn’t have time to talk to physicians."


 Action, April 3, 2012

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    Who ever these 130 are, if they are like me, it will be a blessing to be dropped. Those patients they have that are covered by Aetna and appreciate their services will continue to see them. If they are billing the higher E & M codes it is probably because they are dealing with complex patients or patients requiring a longer amount of time. Patients perceive the high degree of care and will recommend friends and family to them. Those doctors reputations will not be hurt.

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    Doctors who actually spend time with patients are going to bill a lot of level 4 and 5 office visits. The abusive billers usually have all types of other procedures they do excessively, not office visits. This is inappropriate and revolting. I expect I will be in the 130. My patients tell me their care with me is some of the best they ever receive. Deselection should be made on the basis of unethical behavior and billing practices. How do they know these 130 doctors are not seeing very sick patients, or simply seeing patients infrequently and taking care of more issues per visit, thereby saving money rather than increasing costs? This is the total opposite of increasing the emphasis on primary care.

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    This happens because so mnay physicians *downcode* because of fear of audits and penalties. And it's "perfectly reasonable" - from a business point of view - for ins companies to get rid of physicians who don't do this. But now what should also happen - and never does seem to happen! - is that shareholders of public companies like Aetna should get rid of their most expensive executives including people like Mr. Bertolini. It's a defect in the market that it doesn't happen.

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    Aetna should fire their CEO and hire one that will charge less and therefore provide more profit for the shareholders.

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    It's interesting how a corporation still manages to practice medicine wthout a license. Deselecting 130 physicians because they are "too expensive" compared to the peers? Have they bothered to check if these doctors actually spend more time with their patients, vs the 5 minute visit or the visit with the NP or PA? In the true sense these doctors may be actually saving them money by actually taking more time to listen, and therefore not requesting unnecessary tests. Deselecting a physician based on their 99214 or 99215 coding use is absurd. Aetna is one of the few insurances that pay 50% if patients presents with a problem visit during an annual exam. These patients would have to wait for another visit, and miss another day of work, because Aetna is too busy saving money to give to their CEO. There are number of doctors who still believe that taking the time and listening to their patients should remain a priority.

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