After months of negotiations and contract renewals, Aetna and a NICU physician group are in a stalemate that could force Texas customers to pay higher medical bills.
Aetna, owned by national pharmacy giant CVS, said Mednax started the termination of their network agreements in late 2019. Pediatrix, a subsidiary of Mednax, has many US hospitals with highly specialized maternal, fetal and newborn physicians, and dominates many markets in Texas.
Aetna Vice President Richard Gentleman said under its current contracts, Mednax charges up to twice as much as comparable providers, which could be eight times the rate Medicare reimburses.
“Current reimbursement rates from Mednax in Texas remain unsustainably high,” he said. “We can no longer accommodate these exorbitant fees.”
If a deal isn’t closed by July 1, Aetna’s commercial members may have to scramble to find pediatric subspecialists in their network — at least until a new federal law goes into effect next year.
A statement from Mednax, based in Fort Lauderdale, Florida, tells a different story.
They claim CVS Aetna “priorizes profit over access to this critical care for its members.”
“For over a year we have tried to work constructively with CVS Aetna on a contract extension,” the statement reads, “and have extended our agreement several times to avoid disruption to patient care. But despite our repeated efforts, they are unilaterally trying to and drastically cut what they pay our doctors to a level well below the market for the highly specialized care we provide.”
“This is cold and selfish,” the statement added. “Unless CVS Aetna changes its stance, their actions will disrupt care and limit access to essential services for many of their most vulnerable members and their families in the state.”
In response, Aetna officials said it is “dishonest of them to imply that their rates are in line with market rates” and claim that patient care will not be disrupted because Mednax is contractually obligated to respect the rates within the network for existing ones. patients during menopause.
Complicating the matter further is that Aetna and Mednax have spent years battling in court over billing issues, and last year, citing high prices, United Healthcare cut ties with Mednax in four states.
Health policy experts say these types of disputes between insurance companies and medical providers raise questions about the functioning of the health care system and the need for reform.
Insurance companies make deals with hospitals, physician groups and other facilities about the fees they deem reasonable for medical services. Discounts for customers are negotiated with providers with the promise that being part of the network will increase patient volume.
These negotiations on reimbursement rates take place in markets across the country, with individual providers deciding whether or not to participate in specific insurance networks. But if patients receive medical care from an out-of-network provider, they can pay the difference or even the whole bill, depending on their health plan.
Newly enacted consumer protection laws do not always protect patients from high costs, nor do they address network suitability issues when consumers live in areas with few network providers.
Texas has banned emergency surprise bills, keeping consumers with state-regulated health plans from being stuck in the middle of billing disputes.
And after several years of debate, Congress passed a national consumer protection bill in December, making surprise medical bills illegal for insured patients receiving emergency treatment.
The “No Surprises Act” comes into effect on Jan. 1, meaning emergency medical responders will no longer hold patients responsible for paying the balance on out-of-network accounts. Instead, they will enter into arbitration proceedings with the insurance company.
Part of the new law requires insurance companies to keep accurate and up-to-date supplier directories or face a financial penalty. So when a doctor drops out of the network, the consumer does not see him on the website’s list of covered providers and mistakenly seeks treatment from them.
Stacey Pogue, senior health policy analyst at Every Texan, a consumer advocacy group, said the new federal law applies to emergencies or when you can’t choose your doctor. This happens when patients go to a networked facility but don’t know if the doctors are also on the network.
“Parents-to-be who know they are likely to have a preterm or other high-risk birth may think about asking if the NICU is in the network before labor begins. But I’ll bet most parents don’t think about it. to ask,” she said.
Pogue said the higher reimbursement depends on whether the neonatal intensive care units are considered an emergency and unlikely to apply to scheduled specialist care after discharge.
Karen Pollitz, senior fellow at the Kaiser Family Foundation, said it’s a barrier to putting the responsibility on consumers to try to understand the health care billing process.
“The complexity ultimately leaves patients in the dust,” Pollitz said. “Often when you’re faced with this complexity, it’s when you’re sick, or your child is sick, so you don’t have time to sit down and read the fine print in your health plan contract.”