News & Articles

AETNA'S LETTER REGARDING MAC FOR GI ENDOSCOPIES

Aetna has just sent a letter to all participating anesthesiologists to advise of a new policy on paying for MAC for upper and lower G.I. endoscopies. This policy will continue to pay for MAC for patients classified P3 and higher, and also for all endoscopy procedures for all patients younger than 18 or older than 65.

For P1s and P2s between 18 and 65, however, or for claims submitted without a patient status modifier, payment for any anesthesia for endoscopies will be reduced to a rate consistent with the amount Aetna pays for claims for moderate sedation services provided by a second physician (typically not an anesthesiologist). That amount is ¼ or less of the full anesthesia payment, depending on the geographic area. It is unclear whether the payment reduction will apply to general anesthesia and not just MAC, an ambiguity that we hope to have resolved soon.

Aetna consulted with ASA, as it generally does when changing anesthesia payment policies (and also with the American Society for Gastrointestinal Endoscopy). We have now reminded Aetna that we believe it should cover general and MAC anesthesia for patients who cannot be classified as P3 or P4 but are still medically compromised and may need more than moderate sedation. Although the "Dear Doctor" letter doesn't say so, it appears from our conversations that Aetna will likely consider "mitigating circumstances" such as documented airway obstruction or intolerance to standard sedative agents and handle these as it does other "unusual" claims submitted with a request for review. Aetna will probably also distinguish between routine screening endoscopies and more complex endoscopic procedures and allow full payment for MAC or GA in P1 or P2 patients undergoing the latter. On May 23rd and 24th, our key contact within Aetna undertook to bring our concerns to his superiors. As a result, we have every reason to believe that we will shortly be working with Aetna on a written clarification of the mitigating factors and other ambiguities in the letter. With an effective date of September 1, 2006, there is enough time to prepare for a smooth implementation process.

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