Originally shared in the Nov/Dec 2020 PPMA Newsletter

Response provided by Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPC

Q: Why do the Aetna “Silver” PPO Plans Pay Less than Others and Paid Less Medicare Rates in 2020, but in 2018/2019 Had Paid the original Medicare Rates?     

A: The payer in question here is a private payer. Therefore, the doctor contracts are with that payer to determine their fee schedule. This is very different from the public payer, Medicare, where all providers of all types in the same region are paid based on the same fee schedule. When dealing with a private payer, it is up to the doctor to agree to a fee schedule. This is often addressed in the doctor’s contract with the payer. 

Too many of our members sign those contracts without legal representation or sometimes without even reading them at all. The first step in considering what has been submitted here is to check to see if this plan is in violation of the contract the doctor signed. If the payer is in violation of this contract, this is a legal issue between the doctor and the plan. However, if the payer is not in violation of the contract the doctor signed, they are stuck with whatever they agreed to.   

Unfortunately this is not something PPMA can help with too much because PPMA cannot negotiate on behalf of their members, and is limited in what it can do due to antitrust laws.  

To answer the two questions that were handwritten on that form [PPMA’s Peer Review Committee Form], these private plans do not have to pay Medicare rates, and they can adjust their rates to whatever they want as long as the contract the doctor signed allows them to. 

Medicare Advantage plans are required by law to provide the same coverage as original Medicare. This is often a mistake to say they have to provide the same payment, and that is not true. Coverage and payment are two different things. They do not have to pay the same as original Medicare.

The summary is, because this is a private plan, they can do whatever the doctor allows them to do based on the contract they signed. This can all be negotiated and too many of our members just sign these agreements without legal expertise or negotiation.