The requirement, which became effective July 1, states Aetna must pre-certify bronchoscopy, colonoscopy, upper gastrointestinal endoscopy, cystoscopy, hysteroscopy, knee and shoulder arthroscopy and laparoscopic cholecystectomy for physicians who perform these scope procedures in an outpatient facility; physicians who perform these procedures in an office setting (considered non-facility by Aetna) are not required to call Aetna for precertification.
In addition, the article states Aetna will “assist physicians and patients in choosing facilities that may be able to save patients money. When a more cost-effective location for which the referring physician has privileges is available, we will notify the physician and patient of those locations.”
“This is not just for out-of-network ASCs; this is for everyone,” Mr. Shanton says. “This means that while Aetna will continue to try to coerce the patient to go to an in-network ASC versus OON, it will also do the same to in-network centers. Thus, if you are an in-network GI center and a few miles away there is another GI center also in-network, if the other ASC’s contract is for less than yours, Aetna will urge the patient to go there.
“Further, Aetna has stated its intent to try to shift procedures to an office-based procedure practice,” he says. “Going in-network does not make you less liable to arbitrary rules of commercial carriers. We must remain vigilant and aware of what the carriers are doing or proposing.”
View the issue of OfficeLink Updates mandating precertification of outpatient scope procedures (pdf).
Learn more about the NJAASC.
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