Members often think that if they choose a doctor in our network, any care that doctor provides is covered at the in-network rate. However, sometimes doctors perform outpatient procedures at facilities that are not in Aetna's network. This can mean members owe more money because of facility charges.
Starting July 1, 2010, Aetna will require pre-authorization for out-of-network ambulatory surgical facilities.
A new policy will help members save money:
Beginning July 1, 2010, in-network doctors will have to get approval to use an ambulatory surgical facility that is not in Aetna's network. When doctors call for approval, Aetna will encourage them to choose an in-network facility instead. If a member’s plan has out-of-network benefits and the doctor still wants to use the out-of-network facility, Aetna will approve it.
Members will know about the difference in benefits levels:
If after calling Aetna the doctor still plans to use the out-of-network facility, Aetna will send the member a letter immediately. The letter will inform the member that the facility is not in Aetna’s network. Aetna will explain that the facility charges will only be covered at the out-of-network level, and that the member’s out-of-pocket costs would be much lower at an in-network facility. Aetna will suggest that the member discuss the choice with his or her doctor.
This policy will help encourage doctors to think about their patients’ expenses when choosing a facility. It will also make members aware of the increased costs before receiving care, which will help members to make informed decisions about their care.
This information was provided directly from Aetna.
https://www.ithaca.edu/intercom/article.php/20100519094901738