Aetna’s new “level of severity inpatient payment” policy will take effect in less than two months, and the American Hospital Association said it is “deeply concerned.”
Aetna’s policy, set to go into effect Nov. 15, will approve inpatient stays without a medical necessity review but pay the claim at a lower severity rate. If the inpatient stay meets Aetna’s supplemental guidelines, the insurer will pay the claim according to the hospital’s agreement. This plan will apply to facilities participating in Aetna Medicare Advantage or Special Needs Plans for emergent or urgent inpatient stays greater than one midnight. The change’s goal is to expedite reimbursement, according to an Aetna update.
AHA President and CEO Richard Pollack sent a letter to Aetna on Sept. 15 detailing the organization’s concerns.
“This policy could erode the transparency consumers rely on to make informed decisions about their care, undermine important regulatory protections that safeguard patients’ coverage and jeopardize the ability of hospitals to provide high-quality, accessible care to all who need it,” he said.
Instead of receiving an official denial, hospitals will instead have to determine whether they were underpaid and if submitting an appeal is worth it, Mr. Pollack said. Currently, Aetna’s decisions to deny claims are subject to federal regulations; the AHA said the policy will also “shield” the insurer from this oversight.
Another concern the organization has is the effect the change could have on how beneficiaries and regulators assess Aetna’s coverage quality, possibly distorting data used for the Medicare Advantage Star Ratings Program.
“Aetna and its parent company CVS Health committed to shareholders to implement a margin recovery strategy in light of emerging cost trends,” Mr. Pollack said. “But shareholder returns cannot come at the expense of the quality of coverage for Medicare beneficiaries or otherwise compromise the integrity of the Medicare program and the health care system at large.”
