Successfully Concluded Disputes
- Global Periods/Modifier 57
- Issue: Aetna was not paying for certain E&M visits appended with a -57 modifier to indicate decision for surgery thereby extending the global period for surgery beyond that prescribed by CMS in violation of section 7.20(b)(vii).
- Resolution: Aetna changed its payment practices to match CMS’. Physicians will be able to resubmit claims for dates of service from January 1, 2005 until February 11, 2006 (when the policy changed) beginning January 1, 2007. Claims may be resubmitted until April 30, 2007.
- Modifier 25 Dispute
- Issue: Aetna was not paying for certain CPT procedure codes (such as visual acuity screening and developmental testing) when billed
with an Evaluation and Management code appended with a -25 modifier as required by section 7.20(b)(iii).
- Aetna fixed the system to pay the affected codes, effective November 12, 2006. (The chart containing the full list of codes is available on most signatory societies’ websites and www.aetna.com.)
- Aetna paid all the individual petitioners back to May 21, 2003.
- Aetna paid all other physicians’ claims with the affected codes for dates of service back to July 1, 2004.
- Aetna has changed its coding policies regarding pulse oximetry (CPT 94760, 94761, 94762) and urinalysis (CPT 81002, 81003) to allow payment when billed with an E&M code appended with a -25 modifier and reprocessed claims with these codes with dates of service back to May 1, 2006. NB: Physicians must append the -25 modifier to the E&M code to be paid with on these claims.
- A Task Force comprised of State Medical Society and Aetna representatives has been convened to make recommendations on improving the Aetna Provider Website to make it more user-friendly and transparent for physician offices.
- Note: It has recently come to our attention that certain proprietary codes were not eliminated from the system and have resulted in denial of CPT 96110 (developmental testing) when billed with an E&M code appended with a modifier -25. We are working with Aetna to address this issue but physicians should carefully review their EOB’s for this code.
- EKG Dispute
- Issue: Aetna was not paying CPT code 93010 when billed with an E&M code (CPT Codes 99281-99285) appended with a -25 modifier as required by section 7.20(b)(iii). However, because Medicare and some other payors do not require the use of the -25 modifier in order to be paid, many physicians submitted their claims without a modifier and therefore this code combination was considered separately.
- Aetna reprocessed physicians’ claims for dates of service back to July 1, 2004 as a result of resolution of the general modifier -25 dispute.
- Aetna removed the edit entirely effective August 12, 2005, meaning that Aetna has started paying for both CPT code 93010 and an accompanying E&M code (CPT 99281 – 99285) without the need for physicians to append a -25 modifier.
- Physicians had the opportunity to resubmit claims billed without the -25 modifier back to February 10, 2006. Aetna’s voluntary agreement to do this goes further than required by the settlement agreement.
- Add-on Code Dispute
- Issue: Aetna was not paying the add-on codes for myocardial profusion (CPT 78478 and 78480) and CAD mammography (CPT 76082 and 76083) as required by section 7.20(b)(ii).
- Aetna changed its payment policies to pay these codes correctly.
- Physicians had the opportunity to submit claims with these codes for dates of service from January 1, 2004 to May 12, 2005 for myocardial profusion and from January 1, 2004 to March 31, 2005 for CAD mammography.
- Because many physicians had stopped submitting claims with these codes due to Aetna’s then current payment policies, physicians were entitled to submit claims which had net been previously submitted. Aetna’s agreement to allow physicians to file never-filed claims went further than required by the settlement agreement.
- Physicians submitting add-on claims collected over $12 million, demonstrating the value of the compliance process.
- Contract Dispute
- Issue: Aetna’s Provider Physician Contracts did not contain all the provisions required by the settlement agreement.
- Aetna sent a contract addendum to all contracted physicians containing the language required by the settlement agreement and clarifying certain contract terms.
- Specifically, contract addendum clarified that Aetna could not limit communications between physicians and patients, that physicians were not required to file claims electronically and specifically listed key provisions of the settlement.
- Aetna extended the term of the most important terms of the settlement agreement by one year.
- Issue: Aetna had not set its fee schedules to cover costs of certain vaccines in certain markets as required by section 7.14(b).
- Resolution: Aetna updated its fee schedules for the markets included in the compliance disputes and paid physicians.
- Aetna has established a Work Group under the auspices of the Physicians Advisory Board to review Aetna policies on vaccine payments.
- All Products
- Issue: Physician practice which sought to withdraw solely from Aetna’s capitated product was terminated as a participated provider from all other products in violation of section 7.13(b).
- Resolution: Practice was reinstated and claims were reprocessed.
- Overpayment Recovery
- Issue: Aetna had sought recovery for overpayments beyond 24 months in violation of section 7.22 which only allows overpayment recovery beyond such time upon “reasonable suspicion of fraud”. These disputes are all fact specific.
- Resolution: Successful resolutions vary by practice because they facts vary by practice.
Sample Aetna Pending Disputes
- Overpayment Recovery: Several disputes allege that Aetna is seeking recovery of overpayments 24 months old in violation of section 7.22.
- Vaccines (TX): Dispute alleges Aetna not paying cost of vaccine used to prevent cervical cancer in violation of section 7.14(b).
- EOBs: Disputes concern EOB’s sent to non-participating physicians and their patients. Although the EOB’s have been revised to reflect that physicians may bill patients, the EOB’s often state that patients owe nothing or state an amount well below that which physicians believe is owed which the disputes allege is a violation of section 7.21.
- Advance Notice of Fee Schedule Changes: Dispute alleges that Aetna’s revised fee schedule was not available until 24 hours in advance of its effective date in violation of requirement in section 7.6 that physicians be given 90 days’ notice of any material adverse changes.
- Indented Codes: Dispute alleges non-payment of CPT 77377G (3-D rendering) in violation of section 7.20(b)(v).
Successfully Concluded Dispute
- Issue: CIGNA’s blended E&M rates in CT, NJ, and NY effectively downcoded E&M codes in violation of section 7.19.
- CIGNA issued fee schedules in those markets which eliminated the blended E&E rates.
Sample Pending Disputes
- Add-on Code: Disputes allege CIGNA is not paying the add-on code for CAD mammography in violation of section 7.20.
- Modifier 25: Dispute alleges CIGNA has failed to pay CPT 96110 when billed with an E&M code appended with a -25 modifier without posting an exception for that code on its website in violation of section 7.20.
- Overpayment Recovery: Dispute alleges CIGNA is attempting to collect past overpayments without providing the practice sufficient information to evaluate claim in violation of section 7.22.