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Aetna Reimbursement Policy Prohibits Payment for Facility Fees for Office-Based Surgery

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Insurance giant Aetna will not reimburse California office-based surgeries for facility fees, a policy that could affect physician offices across the state.

A Center for Comprehensive Woman Health in Tarzana, Calif., received a letter from Aetna informing the facility that the payor would only reimburse for facility fees or related surgical charges in facilities licensed as ambulatory surgery centers.

According to the letter, physician offices that perform surgeries are not eligible for facility fee reimbursement. This creates a problem for office-based surgeries, which must perform procedures with similar overhead to ambulatory surgery centers without the same level of reimbursement.

Aetna responded to queries with the text of the original policy, which states: " For any surgical procedure, in order to be reimbursed for facility fees or any related surgical care charges … the entity must be properly licensed by the state where the facility operates. Specifically, the facility must be licensed as an ambulatory surgical center or whatever comparable title is used by a state's licensing law to describe a freestanding facility, other than a physician's office, where surgical and diagnostic services are provided on an ambulatory basis."

An Aetna spokesperson said the policy has been in effect since 2006.

The challenge of achieving adequate reimbursement for office-based surgery is not limited to California. Florida physicians Cory Lessner, MD, and Andrew Shatz, MD, who operate SightTrust Eye Institute in Sunrise, say they have met with resistance from payors.

"We believe that since our center follows the same guidelines as ASCs, and we are performing the same surgeries with the same standards of care, it should be reimbursed at a similar rate," they said. "This would allow us to cover rent, staff salaries, disposable supplies and implants."

In New York, too, resistance is growing. In an article on the "facility fee fight," Matthew J. Levy, Esq. and colleagues, wrote that payors have recently "sent out notices to hundreds of providers that not only will they no longer reimburse the physician for the facility fee in the future, they are also seeking repayment of claims paid previously."

The authors said this stance is in "direct conflict" with prior relationships between payors and office-based surgeries.

ASCs seeking facility fee reimbursement can provide evidence to Aetna of Medicare certification as an ambulatory surgery center -- but not simply accreditation by an accrediting agency, such as the Joint Commission, AAAASF or AAAHC.

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