Sample Compliance Dispute Descriptions

    Modifier -25

    Aetna Coding Provisions-Background:   Aetna routinely disallows non-E&M services when billed with an E&M service appended with modifier -25.  Per the Settlement, if a bill contains a CPT code for performance of an evaluation and management CPT code appended with modifier -25 and a CPT code for performance of non-evaluation and management service procedure code, both codes shall be recognized and eligible for payment, unless the clinical information indicates that the use of the modifier -25 was inappropriate or Company has disclosed pursuant to §7.8(c)(iii) that such services are not appropriately reported together."  Aetna has not disclosed that said services are not appropriately reported together.  Additionally, if the same services are billed with a modifier -59 appended to the non E&M service the payor considers both codes eligible.  Modifier -25 and modifier -59 are appended to services for the same reason; to identify distinct services performed on the same day as other services.  Modifier -25 is appended to E&M services to designate the service as distinct and separate.  Modifier -59 is appended to non-E&M services for the same reason.

    Example #1 (Aetna): Procedure code 99173 was billed with 99394-25.  Payment for procedure 99173 was denied.  Per Section 7.8(c)(iii) of the settlement "company shall publish on the Provider's website any circumstances as to which it has determined that particular services or procedures relative to the modifier -25 and -59, are not appropriately reported together with those modifiers …" The combination of 99173 and 99394-25 is not cited as appropriate to report together.  Aetna is not in compliance with Section 7.20(b)(iii); "if a bill contains a CPT code for performance of an evaluation and management CPT code appended with a modifier -25 and a CPT code for performance of a non-evaluation and management CPT code appended with a modifier -25 and a CPT code for performance of a non-evaluation and management service procedure code, both codes shall be recognized and eligible for payment, unless the clinical information indicates that use of the modifier -25 was inappropriate or the Company has disclosed pursuant to 7.8(c(iii) that services are not appropriately reported together."  Per CPT Guidelines (page 298, CPT 2004), regarding procedure coder 99173 "other identifiable services unrelated to this screening test provided at the same time may be reported separately (e.g., preventative medicine services)."  Please forward the provider's full fee schedule allowance for procedure code 99173 as relief.

    Example #2 (Aetna):   Emergency Department Physicians treating Aetna Subscribers, insureds, and Members presenting with signs or symptoms of acute coronary conditions requiring an electrocardiogram, (a service Aetna Policyholders believe to be a covered service) are routinely denied reimbursement by Aetna.  Aetna routinely denies the code (CPT Code 93010; electrocardiogram with at least 12 leads, interpretation and report only) when billed in conjunction with an Evaluation and Management Code, (CPT codes 99281-99285).   This is in violation of Section 7.20 (c)(iii) requiring recognition of both the E&M code and a service procedure code, when appropriate clinical information is provided.  This code is routinely denied even when the E&M code includes a -25 modifier indicating that the E&M service and the 93010 procedure were separate and identifiable from one another.   This is systematically and routinely denied by Aetna without review of the clinical information, indicating that it is a systemic violation of Section 7 of the agreement under Section 12.6(f) of the Settlement Agreement.

    Attachments:   Copies of HCFA 1500 and electronic bills, EOBs

    Timely Payment

    Example #3 (CIGNA): An OB/GYN practice was denied payment on claims due to the patient's failure to select a primary care physician. This has occurred even in the instance when a primary care physician is indicated on the patient's insurance card.  There was no referral requirement, e.g. there has been no failure to obtain required referrals or authorizations. This was a violation of several provisions of the settlement agreement including Section 7.17 (Billing and Payment) and Section 7.23 (Efforts to Improve Accuracy of Information about Eligibility of CIGNA HealthCare Members).

    Attachments:   Copies of HCFA 1500 and/or electronic bills, EOBs and CIGNA Referral Policy.

    Immunization

    Example #4 (CIGNA): The physician was a participating provider with CIGNA. CIGNA HealthCare of North Carolina had established a fee schedule for the licensed meningococcal vaccine (MCV4 or Menactra) at 50% of the physician's billed charges. The vaccine has been recommended by the Advisory Committee on Immunization Practices for certain high risk groups, including adolescents and college freshman living in dormitories. (Attached to dispute) This issue was of particular concern in North Carolina; there have been several recent outbreaks in North Carolina universities.  Each outbreak brings in numerous parents demanding vaccines for their children.  (news article attached)

    CIGNA was paying for vaccine at the rate of 50% of billed charges.  The CIGNA Settlement Agreement says in Section 7.14(b):

    Payment Rules for Injectibles, Durable Medical Equipment, Administration of Vaccines, and Review of New Technologies:  CIGNA HealthCare agrees to pay a fee (per the applicable fee schedule for a Participating Physician and a reasonable fee for Non-Participating Physicians) for the administration of vaccines and injectibles in addition to paying for such vaccines and injectibles. CIGNA HealthCare agrees to pay Participating Physicians for the cost of injectibles and vaccines at the rate set forth in the applicable fee schedule in each market, as in effect from time to time."

    Thus, the agreement states that the cost of injectibles will be reimbursed. By setting individual rates at 50% of billed charges, CIGNA has made it virtually impossible for physicians to recover the cost of vaccine, as required by the agreement.  For example, the cost of the vaccine is approximately $84.  In order to recover its costs, the physician would be required to charge $168 per dose, prohibitively expensive for most patients.  Thus, if the physician's raise their rates to cover costs, it will have the effect of denying the vaccine to other private pay and uninsured patients.  Sending patients to the health department (as recommended by a CIGNA provider relations representative) interfered with the patient-to-physician relationship and interrupted continuity of care. In any event, patients and employers have paid premiums anticipating that medically necessary care will be reimbursed by CIGNA rather than the taxpayer.  Furthermore, a variable rate set at 50% of each practice's billed charges does not constitute a "fee schedule in each market" as contemplated by the agreement.

    Because of the severity and urgency of the matter, we requested an immediate change in its payment policy, and reimbursement of physicians for the cost of their immunization vaccine as of the effective date of the settlement agreement.  In addition, because of its urgent nature and its impact on patient care, an expedited review was requested.

    CIGNA changed their policy, made several months retroactively. We are still contesting the date of payment retroactivity.  (CIGNA contends that the agreement does not in fact require that they pay the cost of vaccine.)

    Attachments:   Copies of HCFA 1500 and/or electronic bills, EOBs and CIGNA Correspondence, Recommendations of Advisory Committee on Immunization Practices and News Articles re: Meningitis Outbreak in Local Colleges.

    All Products

    Example #5 (CIGNA):   An ophthalmologist was advised by CIGNA that in order to participate in the PPO products, he must participate with the HMO products. This product was handled through Opticare, a vision care vendor.  This is in violation of the "All Products" provisions of the settlement agreement as follows:

    7.13   Participating in CIGNA HealthCare's Network.
    b.      "All Products" or "All Affiliates" Clauses.
            CIGNA HealthCare does not include provisions in its contracts with Class Members that require, or purport to require, Class Members to participate in one or more of CIGNA HealthCare's products (e.g., HMO, PPO, POS, indemnity) as a condition of participating in any other product, and shall not include such provisions in its contracts with Class Members at least through the Termination Date. With respect to CIGNA Behavioral Health, unless a psychiatrist, psychiatric group practice or psychiatric facility and CIGNA Behavioral Health, Inc. agree otherwise concerning Covered Services to be provided by that psychiatrist or psychiatric facility, psychiatrists who provide Covered Services to patients for whom CIGNA Behavioral Health, Inc. provides managed behavioral benefit and/or employee assistance program services and network services (both CIGNA HealthCare patients and patients covered under other health benefit arrangements)  are expected to provide such Covered Services to all such patients, subject to Section 7.13.d.

    CIGNA is in violation of this section through its requirement that the physician contract with Opticare in order to retain his participation in CIGNA HealthCare's network.  Please note that vision care programs are not mentioned in Section 7.13(b); CIGNA Behavioral Health is the only exception to the all products prohibition.

    Attachments:   CIGNA Correspondence, Opticare Provider Directory.


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