MSSNY Fights for New York Physicians: Pushing Back Against Aetna’s Downcoding Policy
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Colleagues:
MSSNY is pushing back against Aetna’s new downcoding policy, which automatically reduces the level of Evaluation and Management (E/M) codes on physician claims without reviewing the supporting documentation. This week, I sent a formal letter to Aetna demanding that the insurer immediately withdraw this policy, citing its potential inconsistency with state insurance law, AMA CPT coding standards, and its harmful impact on New York physicians and their patients:
Dear Dr. Golash:
On behalf of over 20,000 physician and medical student members of the Medical Society of the State of New York (MSSNY), we write to urge that Aetna reevaluate its reimbursement policy, Evaluation and Management (E/M) Program Claim & Code Review. The policy appears to state that claims for higher-level services for certain physicians will be downcoded based solely on the data submitted on the claim form. Several physicians have brought concerns to our attention about the implementation of this policy.
MSSNY strongly opposes automatic or unwarranted downcoding of claims, and we strongly disagree that changing the E/M CPT code to a lower level would result in improved claims accuracy.
It is also unclear how Aetna’s reimbursement policy is being sufficiently disclosed to physicians, to align with nationally recognized standards for coding and billing, or to consider CPT coding criteria in determination of level of service, and in doing so it increases administrative burden and costs for both physicians and Aetna. Downcoding to a lower level is in effect changing the medical record to a CPT code that was not initially billed by the physician’s office. Read the full letter here.
All the best,
David Jakubowicz, MD, FACS
MSSNY President
