At Aetna, we want to work together with the medical community to help improve the quality and cost effectiveness of health care for our members.
Our primary goal is to put our members’ welfare at the center of everything we do. We recognize that we cannot accomplish this without strong working relationships with our members’ physicians and other health care providers. We have worked hard to change past practices that were not consistently transparent and respectful of providers. This set of Guiding Principles is intended to demonstrate that we are serious about continuing to build the best possible relationship with the medical community, as this is central to ensuring our members get the highest quality and affordable care.
The Guiding Principles are intended to guide our actions as a company. We have included details on some specific commitments we intend to follow in the future, once the settlement agreement that we reached with the physician community expires. As should be clear, we have no intention of reversing course. Instead, we want to move forward and continue to be the high-integrity business partner that health care providers need.
Aetna’s Guiding Principles
Build Effective Relationships
We will strive to accommodate physicians’ interests while providing members access to quality, affordable health care and remaining competitive in the marketplace. We will support, not intrude upon, the physician-patient relationship.
Improve Health Care Quality
We will give doctors and hospitals information that facilitates quality, cost-effective care, and we will work with them even more closely in the future in an effort to promote evidence-based medicine, enhance patient safety and eliminate wasteful processes. In particular, we will offer integrated information to help members and physicians make better health care decisions. We also will continue to establish clear clinical, evidence-based policies that are transparent to physicians, hospitals and members.
We remain committed to making our business processes as simple and transparent as possible. We recognize the value of health care professionals’ time. We will identify and implement ways to make it easier for physicians to do business with us. We want them to understand our processes and procedures, and we will commit to doing our best to create fair processes and procedures.
Invite Respectful Dialogue
We will listen actively and have frank, respectful conversations with physicians and other health care professionals in all matters. We remain committed to seeking input, advice and alternative views of our policies. The health care system is complex, and ensuring that care is both high quality and cost effective is never straightforward. We want health care providers to understand our reasoning, and we want to know their views on our plans for helping our members attain high-quality care.
Aetna will work to make it easier for physicians to do business with us.
- We will continue to collaborate with other health plans to identify industry-wide solutions aimed at reducing administrative complexity and improving health care quality.
- We will resolve as many claims as possible on initial submission so as to decrease the number of resubmitted items.
- We will continue to make available an independent, external medical necessity claims review process, just as we do for our members.
- We will continue to expedite credentialing of providers and allow early submission of materials.
- We will allow physicians and physician groups consisting of fewer than five Participating Physicians to terminate from our network 90 days after we receive their notice, with no need to show cause.
- We will continue to allow submission of claims up to 120 days following provision of service.
- We will maintain our moratorium on seeking overpayment recovery of claims older than 24 months, unless there is suspicion of fraud or a pattern of abusive billing.
- We will improve members’ awareness of the concept of a pharmaceutical formulary and will ensure that ours is applied fairly.
- We will continue to educate members about their benefits so they can make more informed decisions.
Aetna will continue to simplify processes and improve access to information.
- We will continue to streamline communications and enhance our Internet and clearinghouse capabilities.
- We will eliminate unnecessary interactions, such as certain referrals and precertifications.
- We will continue to maximize automated claims adjudication, a business practice that speeds payment and is good for providers, members and Aetna.
- We will continue to exempt practices from utilization review programs when it is clear that providers are rendering high-quality, cost-effective care in the area covered by the program.
- We will continue to operate full-service provider service centers, where physicians can address all of their practice and payment issues.
- We will ensure that our website for health care providers is up-to-date and reliable.
- We will not use pharmacy pools.
Aetna will continue to make our business processes as transparent as possible.
- We will continue to make fee schedules available for participating providers 90 days prior to the effective date of any change.
- We will provide transparent information on our claim check logic and continue to work with providers to ensure consistency in bundling and other claim policies.
- We will continue to disclose all precertification requirements on a timely basis.
- We will not use all-product or “gag” clauses in contracts.
- We will commit to a 15-day turnaround on electronically submitted claims and 30-day turnaround for claims submitted on paper.
- We will not engage in automatic downcoding, except in those cases where there has been an investigation and full notice.
- We will continue to use the new definition of “Medical Necessity” in our contracts.
Aetna will maintain and strengthen a variety of forums through which we have important ongoing dialogue with the medical community.
- We will continue our Physician Advisory Board (PAB) and seek input from organized medicine about Board membership and topics.
- Through interaction and cooperation with the Physicians Advocacy Institute, we will maintain an open dialogue with the medical societies who were original parties to the Physicians Settlement Agreement with Aetna.
- Through participation in the Physicians Foundation for Health Systems Excellence, we will advance the work of practicing physicians and work to improve the quality of health care for all Americans.
- Aetna’s senior leadership will continue to make visits to the medical societies to listen to their insight and to dialogue on key issues.
- Claims software editing will continue to be a focus of the PAB, in order to reassure physicians and other providers that we are committed to transparency.
- We will continue to assign medical directors as primary liaisons with state, national and specialty medical societies to help us better address physicians’ issues and ensure that Aetna’s business decisions take into account physicians’ concerns.
- We will continue to solicit specialty society advice when we develop our Clinical Policy Bulletins.
- We will continue to survey physicians to gain input on new initiatives and to measure satisfaction.
Aetna will support real-time decision-making for members and physicians.
- We will continue to expand our efforts to support clinical decision-making.
- We will make clinical information from our clinical data repository available in real time for physicians as they see patients.
- Health advocacy, case and disease management, and coaching programs that Aetna uses to promote member health will be made available to physicians through electronic linkage, either through the Web or through a physician’s electronic medical record.
- Information on prescription drugs and advice on drug-to-drug interactions and other patient safety issues will be shared with any physician who e-prescribes.