Aetna: Valley Sante patients may need new doctors [The Fresno Bee]

Aug. 31--Thousands of people in the central San Joaquin Valley with Aetna health insurance could have to pick new doctors -- or pay a lot more to be seen -- beginning Saturday.

Aetna has mailed letters, some arriving only this week, to notify people whose doctors are part of Sante Community Physicians that their doctors will be leaving the insurer's network of providers on Sept. 1.

The insurance company ended the contract it had with Sante, which represents about 1,200 doctors in Fresno, Madera and Kings counties.

Aetna is negotiating individual contracts with doctors, but it is not known how many will sign with the insurance company.

Patients who have Aetna health maintenance organization (HMO) plans and Medicare plans are not affected.

The patients who are affected have preferred provider organization (PPO) plans and Sante</org> doctors. Under most PPO plans, patients can choose doctors from within a network or pay more and go outside of it.

Sante medical director Dr. Daniel Bluestone said his group has negotiated a PPO contract with Aetna for a number of years, but in December it was told that Aetna wanted to reduce the rate it was paying doctors to see PPO members.

Sante "could not as a medical association in good faith recommend our doctors accept that," Bluestone said.

Aetna has no quarrel with Sante, said Anjie Coplin, Aetna regional director of communications. "We've made the decision to go in another direction," she said in an email.

The Sante contract termination has nothing to do with a rift between Aetna and doctors statewide over PPO referrals that resulted in a lawsuit filed in July by doctors outside the Valley, Bluestone and Coplin said.

But with the contract termination, Sante doctors must decide on their own whether they want to sign contracts with Aetna to continue providing care to patients, Bluestone said.

At least one major medical group -- Fresno-based Community Medical Provider -- has chosen not to sign. The group, with 33 doctors, has about 2,500 patients.

"It was going to pay us less than Medicare," said Dr. Grant Nokamura, the group's medical director. "From our standpoint, we take Medicare, but that's about as low as we can go. We're a business, just like anybody else is a business. We can only accept rates so low."

But Coplin said many doctors are accepting Aetna's terms. "We are receiving contracts back literally by the minute," she said Thursday afternoon. She wouldn't say how many doctors had signed.

Contracts will be extended to individual doctors after Sept. 1, the termination date for the Sante contract, Coplin said. Aetna PPO members should check next week with their doctors to verify whether they've contracted with the company, she said.

The mailed notices gave patients little time to find new providers before the Sept. 1 cutoff. California law does not require insurers to notify PPO policyholders prior to contract terminations, said Janice Rocco, state deputy insurance commissioner. The state Department of Insurance, however, is sponsoring a bill that would require notification under certain circumstances, she said. Assembly Bill 2152 passed the Senate on Wednesday, she said, and was headed back to the Assembly with revisions.

The goal of the legislation is to "make sure that patients who have been seeing their physician and paying an in-network rate don't go back to that same physician without knowing that they're now out-of-network and they will be charged significantly higher costs for the health care services they're receiving," Rocco said. And the department wants to be notified about contract terminations so it can make sure the company has an adequate network of providers, she said.

Aetna provides for a transition of care for patients losing their doctors, Coplin said. Aetna members should bring a transition of care form to their doctor to fill out. The form will be reviewed by clinical staff and approved or denied, she said. If approved, the member can continue treatment for up to 90 days.

The reporter can be reached at (559) 441-6310, [email protected] or @beehealthwriter on Twitter.

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