The New Jersey Department of Banking and Insurance says a managed care company has taken the wrong approach to trying to control the cost of out-of-network care in in-network hospitals.
The department is preparing to impose a $9.5 million fine on Aetna Inc., Hartford, in connection with a letter Aetna sent to New Jersey health care providers in June.
Aetna told providers it would set a “fair payment” limit equal to 125% of the Medicare allowable amount for certain types of medically necessary care provided by doctors outside the Aetna provider network, and 75% of the Medicare allowable amount for lab fees and durable medical equipment.
The “fair payment” rule was supposed to apply to emergency care and other state-mandated services provided by out-of-network providers while a patient was admitted to an in-network hospital to services rendered as the result of a referral or authorization by Aetna, New Jersey regulators say.
Aetna told providers that “additional reimbursement would not be considered,” officials say.
In some cases, the rules led to patients receiving bills for amounts over what Aetna defined as the fair payment level.
In New Jersey, members of a health maintenance organization have the right to “be free from balance billing by providers for medically necessary services,” officials say.
New Jersey insurance regulators received complaints about the new Aetna payment rules, officials say.