Overview of Aetna’s contracting and
credentialing process for Medicare
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
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
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
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
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
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: [www.aetna.com].
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
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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 Leverage national credentialing process Update Systems
When identified in Aetna provider systems as Medicare Advantage participating, a provider is flagged to print in DocFind
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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
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
Medicare Private Fee-For-Service Provider
Communication and Education
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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
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.
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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
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.
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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
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
Aetna.com
http://www.aetna.com/members/medicare/medicare_
open_plan.html
Aetna Medicare Open Plan Terms and Conditions of
Participation (Updated 06/14/07)
Aetna Medicare Open Plan Reimbursement Grid
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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)
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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)
(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
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