APMA met with Aetna recently to address members' concerns about the payer's downcoding of certain claims, under its Evaluation and Management (E&M) Claim and Code Review program. APMA also gathered information about the reach of the program and the lines of service impacted, as well as identified strategies that can help address this issue effectively.
Impact and Reach for Podiatrists Impacted by Aetna Downcoding
Aetna indicated that less than one percent of podiatrists in its commercial plans have been entered into the program. Additionally, for podiatrists in the program, more than 90 percent of billed claims were approved and paid at the Level 4 or Level 5 billed originally.
Aetna’s specific program applies to commercial plans only (i.e. no Medicare Advantage claims are adjusted under this program) but is nationwide in application and applies to all provider types. The vendor conducts a yearly analysis of all applicable providers to identify over users. Claims will never be adjusted to less than a Level 3 reimbursement. Aetna noted that no providers’ claims are universally adjusted downward—the vast majority of the providers in the program have their claims approved at the original level billed. Finally, Aetna's vendor evaluates all applicable providers on an annual basis.
Identifying if Your Claims Are Impacted and Next Steps
In order to address this issue, providers need to be vigilant about reviewing their claims and reimbursement. If your practice is identified for this Aetna program, you will see it on your claims and EOBs in the following forms:
EOB message:
The consult, billed diagnosis or services do not match the E&M service reported. Our payment reflects the more appropriate E&M code. If you believe that the consult code or E&M service billed accurately reflects the services provided, you have the right to dispute. Please submit any new information, such as the medical records or related documents, to us through the normal dispute process. [R11]
ERA message:
N22 - ALERT: THIS PROCEDURE CODE WAS ADDED/CHANGED BECAUSE IT MORE ACCURATELY DESCRIBES THE SERVICES RENDERED
It is critical to appeal any and all claims you believe to be inappropriately downcoded. Aetna confirmed to APMA that if a provider successfully appeals and overturns a certain threshold of adjusted claims, over a period of approximately 5–6 months, they will remove that provider from the program early and will not reassess that provider under this program for three years. Aetna also stressed that the impacted provider would need to be proactive and reach out directly to its plan representatives to request early review and removal.
Members can see the full Aetna policy and instructions for appeal here.
APMA continues to actively explore additional strategies to limit downcoding practices and ensure fair reimbursement for providers, but in the meantime, strongly recommend utilizing the above strategies to limit the impact of this policy to your practice. Visit www.apma.org/EM for more information about documenting and coding EM visits.