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Important: Aetna Amends Participating Provider Agreement!


The ANJC has received information from membership that Aetna, Inc., has proposed amendments to its participating provider agreements with doctors that participate in their workers compensation network. The notice from Aetna indicates that your participation in Aetna’s workers compensation and auto injury networks will be assigned to Coventry but only as to Coventry’s workers compensation product. This is a result of Aetna’s acquisition of Coventry Health Care, Inc.

The ANJC cannot advise any member as to whether they should accept or reject such amendments or make any changes to their participation status, and provides this as informational only. The key provisions of the amendments are as follows:

  1.  Mandatory Arbitration /Class Action Waiver: You agree to arbitrate any dispute under the agreement and waive your right to go to court. You also agree not to participate in any class action against Aetna at any time in any capacity.
  2. Lease of Network / Silent PPO: Aetna reserves the right to lease/rent the network to other third party payers. They do not have to get your permission to do so.
  3. Payment: You will accept the Aetna in network compensation rates to treat Coventry insureds and cannot balance bill the patient. You also waive your right to bring litigation for the rate reimbursement methodology by signing the Addendum.
  4. IMEs/Other: The carrier can request that you perform an IME on a patient and provide a permanency evaluation pursuant to the AMA Guidelines to Physical Impairment. You may also choose to perform other services such as pre-employment screenings.
  5. Audits: If the payer audits your claims, you agree to repay any overpayments within 45 days of their demand for repayment.
  6. Billing: Payer must receive bills within 90 days of date of service or they have the right to refuse payment. You cannot balance bill patient if you miss this deadline.
  7. Mandatory Appeals. You must file any appeal of a reimbursement denial or underpayment within 180 days or waive your right to further proceedings to compel payment.
  8. Lock-In Time Frame: You are locked in to this addendum for 12 months wherein you cannot terminate it; after 12 months you can terminate upon 90 days prior, written notice.

Again it is each individual member’s decision whether to accept or reject these amendments based upon their practice’s specific needs. You are requested to sign the addendum and return it to Aetna within 15 days of receipt. If you do not sign it, you could be terminated from the Aetna workers compensation / auto injury networks.

There may also be wind down provisions in your participating agreement which will delay the effective date of your termination if you choose to reject the amendments after 12 months. You will have to review your own participating agreement to determine these requirements.

Jeff Randolph, Esq.
General Counsel to the ANJC