Aetna is continuing a campaign of lawsuits against providers whom it deems to charge too much for out-of-network services. Some suits are a year old but still being resolved, and it appears that the insurance plan could very well win some of them.
 
Without a participation agreement and an agreed-upon fee schedule, the sky is literally the limit for some physicians, including a Texas surgical group that dared to charge $99,750 for ear wax removal.
 
That figure certainly seems ridiculous for a code like 69210 (remove impacted ear wax), which Medicare pays $53 for in Houston, but many practices find themselves with little option but to see some portion of out-of-network patients. For these patients, which present a significant administrative burden, practices should be compensated fairly.
 
Judging from Aetna’s aggressive counterattack, the strategy of charging an absurdly inflated figure in hopes of getting some reasonable amount as a fraction of it is clearly a bad one, however.
 
Unfortunately, very few practices actually base their charged amounts on reference data that is local to their market.
 
Such data has historically been available in print books, but online workflow tools such as DecisionHealth’s own FeeCalc are becoming more popular, especially among consultants and provider organizations dealing with out-of-network issues.
 
Free webinar: Check out best practices in fee-setting and comparison, along with a demonstration of FeeCalc, in this July 25 webinar.