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Texas Medical Association and other plaintiffs suing for-profit HMOs have resolved their dispute with Aetna over payment of claims with the modifier 25. At issue was Aetna's repeated rejection of modifier 25 and other CPT modifiers attached to evaluation and management (E&M) codes. Modifier 25 is used to indicate that the E&M code is a significant service distinct from a procedure performed that same day.
In a mediation consent order issued this week, Aetna agreed to:
- Pay physicians who filed modifier 25 disputes pending as of May 1, 2006, for the disputed codes back to May 21, 2003. The codes are listed on the TMA Web site. Aetna must make these payments within 90 days.
- Rework all disputed claims involving the listed codes. Applicable dates of service are from July 1, 2004, through April 30, 2006. Physicians entitled to payment retain their right to appeal Aetna's payment determination as established by their contract with the company. Aetna must pay a 6-percent penalty for claims unpaid on Oct. 1, 2006.
- Change its claims payment software "as soon as practicable" to allow payment of the listed codes. Meanwhile, Aetna will work with a facilitator and the plaintiffs to develop a process to pay physicians from May 1, 2006, until the system is changed permanently.
- Reprocess claims containing codes represented by the changed payment policies back to May 1, 2006.
- Work with the plaintiffs to establish a "Strike Force" of physicians and health care financing experts within 30 days to review Aetna payment policies that result in non-payment of certain codes, including codes appearing on Aetna’s incidental list, experimental and investigational list, and other lists of codes for which Aetna has established policies not to pay. Aetna also agreed to use the Strike Force recommendations to change its payment policies; based on historical billing patterns, this would increase its annual payments to physicians by at least $1.7 million. The company will publish any such payment policy changes on the Aetna Web site.
- Establish a task force with physician representation to review the Web site to make it more user friendly and transparent for physicians.
Aetna also agreed to pay for experts to review complaints filed by physicians who believe Aetna is not living up to terms of its settlement of the lawsuit. Additional details will be available on the TMA Web site at www.texmed.org/rico, at www.hmosettlements.com, or on the Aetna Web site.
Last Published: 5/12/2006 Print this page
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