Last month, we wrote about the updated Aetna Medicare SOI policy and what it means for inpatient reimbursement. Since then, we’ve been watching how this plays out operationally, and the picture is more complicated than the policy summary suggested.
What we’re seeing from the Aetna Medicare SOI policy that Revenue Cycle Leaders should watch:
1) Your system probably isn’t flagging the denial of inpatient payment by default.
Aetna Medicare is issuing RARC N610 paired with CARC 45 to communicate SOI-related payment reductions. However, this combination doesn’t register as a denial in most revenue cycle workflows. It clears as a processed claim. If your system is set up to flag payment variances, these cases are likely being grouped together with other payer underpayments which can reduce transparency into the impact of this new policy.
Setting up the combination of N610 and CARC 45 to create a denial record can facilitate better tracking of these cases.
2) By the time you hear about it from UR, it’s already late.
Aetna’s SOI notification via 835/adjudication lags significantly behind the notice to utilization review teams. If your workflow depends on 835/payer adjudication to trigger action on these claims, you’re operating on a delay resulting in increased AR aging and a reduction in the time to request P2P and reconsiderations/appeals. In some cases, the window to respond has already narrowed by the time anyone internal knows there’s an issue.
3) Inpatient status isn’t getting corrected and it’s distorting metrics.
When Aetna adjudicates an inpatient claim at an outpatient rate, many organizations leave the claim in inpatient status. That mismatch inflates expected reimbursement and skews net collection rate reporting. Historically, many level of care denials often resulted in the downgrade of the patient admission to an outpatient/observation status to align expected with actual. If your workflow isn’t doing that, your performance metrics are telling a different story than your actual reimbursement revenue.
4) Faster adjudication sounds good. It creates a new accountability problem.
With the new Aetna Medicare SOI policy, Aetna has indicated it will adjudicate these claims more quickly. On the surface that’s a positive, reducing AR aging. But faster adjudication means less time to catch errors before they close, and it puts pressure on health systems to hold Aetna accountable to that timeline. If you’re not tracking adjudication speed by payer and claim type, you won’t know when they’re not holding up their end, or when you’re losing appeals windows (this is something Sift’s cash forecasting and predicted payer response tools can help with).
5) Academic medical centers have an open compliance question.
For health systems that receive Medicare IME payments, when Aetna adjudicates an inpatient claim at an outpatient rate but the patient remains in inpatient status, the question of how to handle the IME payment is not settled. This sits at the intersection of billing compliance and legal, and many organizations haven’t had that conversation yet. It’s worth having it before the volume builds.
6) DRG downgrade risk hasn’t gone away, SOI is simply another operational challenge to account for.
Aetna Medicare continues to pursue DRG downgrade denials concurrently with SOI adjudications. These are two distinct revenue impacts that may be tracked separately in your system and worked by different teams, but are hitting the same reimbursement.
If your team is heads-down on the SOI issue, make sure you’re not missing the downgrade exposure sitting underneath it. As highlighted in Sift’s Annual Denials Insights Report, DRG downgrades have been a growing theme across payers (Aetna is no exception).
These six impact points are operational realities that revenue cycle teams are navigating right now, most without purpose-built tools to catch them. If you want to understand how this policy is affecting your Aetna book specifically, what you’re losing, where it’s hiding, and what’s recoverable, Sift can help with that analysis.
