ASHN Contracts With Aetna to Administer Chiropractic Services – June 17, 2011 Deadline For Applying

ICS Member Alert – American Health Specialty Networks (ASHN) Contracts with Aetna to Administer Chiropractic Services – June 17, 2011 Deadline for Applying to Avoid Gap.

ICS members who are part of Aetna health plans should have received notice that Aetna has contracted with American Health Specialty Networks to administer chiropractic benefits for Aetna plans, including Medicare Advantage. In order to remain in Aetna’s network, providers must apply directly to and become credentialed by ASHN.

Some ICS members have contacted the ICS to learn details about the plan to assist them in deciding whether to apply. The ICS is prohibited by law from advising members whether they should or should not join a particular network or health plan. However, the law permits the ICS to provide factual information about health plans. In order to get the most accurate information, the ICS initiated a conference call with ASHN and Aetna to learn their understanding of plan details. ASHN and Aetna provided the following information regarding their administration of chiropractic benefits:

Overview Per ASHN and Aetna

Aetna has a relationship with ASH in several states including AZ, CA, Washington D.C., DE, PA; and is looking to expand relationships in many jurisdictions. According to ASHN, they have 20,000 providers and 14 million members, and the majority of currently contracted providers join ASHN.

Coverage is limited to neuromusculoskeletal conditions only.

There is no coverage for any other type of care, including primary care. Aetna does not recognize DCs as primary care doctors.

Reviews are 100% peer-to-peer.

ASHN employs full-time chiropractic physician reviewers to review chiropractic cases. ASHN has 20 chiropractic reviewers who must go through the same credentialing as the doctors participating in the network.

ASHN makes determinations on a case-by-case basis and provides facts and support for denials. 

Following a review, ASHN provides the name and contact number of its reviewer to the provider. ASHN does not use computer algorithms to make determinations of payment.

Reviewers follow Clinical Practice Guidelines comparable to existing Aetna Clinical Policy Bulletins. The guidelines can be found on ASHcompanies.com (click on Provider tab).

The appeal process is URAC (formerly Utilization Review Accreditation Commission) accredited and follows regulatory requirements.

For evaluation of whether a technique is investigational, experimental or not recognized reviewers consider if it is taught in the core curriculum; used in clinics affiliated with educational institutions, or recognized in journals. If there is a lack of evidence for the procedure (as opposed to negative evidence), the reviewer will ask if it is reasonable to consider using the procedure. The case is then reviewed by the Peer Review Committee.

Handling of ASHN Patients/Documentation 

The ICS inquired as to what procedures and paperwork must be utilized with ASHN/Aetna patients, from the time of the first visit. The ASHN/Aetna representatives advised that the doctor should take a history, perform an exam and formulate a treatment plan as usual. Typically ASHN will not require proof of medical necessity until after the 5th visit for 3rd Tier providers. If the patient requires more than 5 visits, doctors should summarize clinical information through the website on ASHlink to show medical necessity.

How often must paperwork be submitted? In 2010, 75% of patients could be seen without extra paperwork. Usually, patients receive 30-day plan approval for acute conditions. For some chronic conditions, ASHN will approve for 60 days – a few get 3 months for acute care.
 

Provider’s Tier is Key

We asked ASHN which visit triggers a review. They indicated that the provider’s tier is key. Depending on the tier, it could be the 6th, 9th, 13th visit or, in some cases, there is no specific number of visits that triggers a review.

Even if providers are using electronic health records (EHR), they can’t merely submit their notes when records are requested for medical necessity determination. Medical necessity information must be submitted in the ASHN Clinical Summary form so that all information is submitted in a consistent format. ASHN strongly prefers electronic submission and will turn around in less than 1 day for a response. However, verification of medical necessity and eligibility can also be provided in paper form as long as standard ASHN forms are used.

Additionally, ASH wants to get providers on ASHlink, and providers should complete the training webinar after they sign up for ASH. The provider will first have to put patient information into the ASH system, then put the patient information into ASHlink to check eligibility.

Network Assignment/Silent PPOs

ASHN indicated that there is an opt-out provision for affiliate payers – ASHN says providers will not unknowingly become members of “silent PPOs” by signing on with ASHN.

Network Provider Fee Schedule/Balance Billing

The Illinois Chiropractic Society, as with all formal and informal groups and organizations, is precluded from discussing fees or negotiating on the doctor’s behalf. However, ASHN has indicated they will be providing updated fee schedule information to physicians by mail in the near future. In the meantime, providers may call their provider recruiters for information. For out of network – reimbursement will be the same as it is now for providers who are out of network with Aetna.

Balance billing issues: patients are “held harmless” for services ASHN determines are non-medically necessary if the patient does not sign a form acknowledging such in advance of service (similar to Medicare’s ABN form). If a claim is determined to be non-medically necessary after the fact, such as following an audit, the provider still cannot bill the patient since no ABN-like form was signed before treatment.

MRI’s and CAT scans

In our conference with ASHN and Aetna, they indicated there would be a requirement for MD or DO referral to determine medical necessity for MRI or CAT scans. However, after discussion with Dr. Joseph Ferstl, ICS Second Vice President (who participated along with ICS staff in our original meeting), ASHN has advised us that they are modifying this provision to allow DCs to order MRI or CAT scan studies.

June 17, 2011 – if the provider’s application is submitted by that date, the provider may treat Aetna patients during application review if currently a member of Aetna. However, Aetna will start termination proceedings for providers who do not apply by June 17, 2011.

Providers who do not apply by June 17, 2011, can still apply but will be treated as out of network as of July 1, 2011, until they are approved, so it is important to make the June 17 deadline for providers who want to stay in network. Credentialing takes about 45-50 days.

Conclusion

If providers need assistance with the application, they may review FAQs on ASHN’s website, OR they may write to Dr. Lloyd Friesen, D.C. at ASHN [add address], and ASHN will send a representative to the provider’s office.

Provider webinars will be presented on June 16, June 30, and July 7, for those who join the network. They are not available before applying.

Resources

The decision to join a network is an individual one. By providing this information, the ICS in no way intends to suggest or imply a recommendation regarding that decision. For general information to consider when considering joining any health network, see Dr. Mario Fucinari’s article Managed Care Contracts: Read Before You Sign on the ICS website.