Overview of Aetna s contracting and credentialing process for Medicare

Transcription

1 Overview of Aetna s contracting and credentialing process for Medicare

2 Aetna leverages a well-developed commercial provider network Aetna supports market-based contracting teams with consistent national network development and contracting strategies including: Competitive network configuration standards Consistent financial models Sharing of Best Practices Development of collaborative contracting models and Pay for Performance programs Strategic opportunity to communicate, outreach and educate providers on Medicare Advantage Plans

3 Considerations for evaluation of Medicare expansion areas: The number of Medicare eligibles located in a given geography Available competitive market information Alignment with commercial products Opportunity for sustained long term product viability and value proposition The ability to develop a robust Medicare Advantage network and effectively manage member care

4 Medicare Advantage HMO/PPO HMO Available in selected Commercial HMO licensed markets PPO Available in HMO markets and some PPO only markets All Medicare Advantage HMO/PPO plans must meet CMS required network access standards Network is fortified consistent with network contracting strategy Medicare Advantage PFFS Non-network based product with no provider contracts A Medicare Advantage Private Fee-for-Service plan works differently than a Medicare supplement plan. Your doctor or hospital must agree to accept the plan s terms and conditions prior to providing healthcare services to you, with the exception of emergencies. If your doctor or hospital does not agree to accept our payment terms and conditions, they may not provide healthcare services to you, except in emergencies. Providers can find the plan s terms and conditions on our website at: [

5 All new members, including PFFS member receive a Health Risk assessment (85% completion rate) High risk members receive comprehensive screening for case management 17 percent of members enrolled in case management programs as of January 1, 2007 Piloting new programs for home case management and institutionalized members Aetna Case Managers are nurses, social workers, behavior health and disease management specialists trained geriatrics and behavior change management Specialized programs: End-of-life care management Dementia care management Institutionalized elderly management

6 !" Identification Target providers consistent with contracting strategy Identify provider needs through your Broker Liaison Contract Most already participate with commercial products Credentialing Leverage national credentialing process Update Systems When identified in Aetna provider systems as Medicare Advantage participating, a provider is flagged to print in DocFind

7 ! # Credentialing: Through the credentialing and re-credentialing process, Aetna validates physicians certification and queries resources such as the National Practitioner Databank Aetna s credentialing team leverages the efficiency provided by the Council for Affordable Quality Healthcare (CAQH), a collaborative initiative designed to simplify healthcare administration. Providers complete web-based applications A central web-based repository reduces duplication Physicians provide payors with access to their applications Through CAQH, Aetna validates licensure and any reports to the National Practitioner Database

8 Medicare Private Fee-For-Service Provider Communication and Education

9 $ % &$ Targeted mailings based on claims data to over 200,000 providers. OfficeLink Updates (provider newsletter articles) bi-monthly updates regarding new tools, resources and education opportunities. Recorded webinar explains Aetna s Medicare Advantage Private Fee-for-Service plan, including its key features and the benefits to providers. Provider seminars in strategic growth areas. Regular updates on our websites regarding the Aetna Medicare Open Plan.

10 $ Dedicated team of associates in place since February 2007, performing provider outreach and education regarding the Aetna Medicare Open Plan. Calls made to providers when a member or provider has questions regarding the Aetna Medicare Open Plan Terms and Conditions of Participation before treating or accepting a member. Proactive calls to providers located in targeted regions of the country where there is interest in the Aetna Medicare Open Plan.

11 $ Observations and Provider responses: Because our discussions are informational, providers appreciate that Aetna is performing this outreach before patients walk through the door. In our experience most providers object to the PFFS product because they do not have a clear understanding of the product, and this situation can be quickly and effectively addressed through provider outreach and education. To date, we have received positive responses from providers regarding the ease of plan administration, no referral requirement, no capitation, and single billing and payment.

12 ' ( & $ Aetna.com open_plan.html Aetna Medicare Open Plan Terms and Conditions of Participation (Updated 06/14/07) Aetna Medicare Open Plan Reimbursement Grid (Updated 8/13/07) Aetna Medicare Open Plan Sample ID Card Aetna Medicare Open Plan Sample ID Card with Rx Aetna Medicare Open Plan Quick Reference Guide (QRG) (Updated 07/13/07)

13 ' ( & $ What Health Care Providers Need to Know About Private Fee-for-Service Plans CMS Provider Letter Aetna Medicare Open Plan Provider Q&As "Zero" Copayments for Preventive Services (Updated February 2007) Aetna Medicare Open Plan Summaries of Benefits for Individuals Medicare Vaccine Information - April 2007 HCFA/CMS 1500 (physician) claim form and UB 92 HCFA 1450 (facility) claim form