Resolution of Aetna RICO Lawsuit Settlement Compliance Issues

Aetna agreed to change its business practices as part of the settlement of a federal antiracketeering lawsuit filed against the company and other for-profit HMOs by the Texas Medical Association and 18 other state medical societies. However, that was only part of the battle. Since then, attorneys for TMA and the other plaintiffs have been closely monitoring Aetna's compliance with the settlement terms. When Aetna was found to be violating the agreement, the attorneys resolved the disputes in physicians' favor.

For more information about Aetna compliance issues, e-mail Deborah J. Winegard , the compliance dispute facilitator for the Aetna settlement. See TMA's Billing Dispute Guide for information on how to file a compliance dispute. 

Here is a summary of the resolved settlement compliance disputes:

Global Periods/Modifier -57

Issue: Aetna violated the settlement by not paying for certain evaluation and management (E&M visits appended with a -57 modifier to indicate a decision for surgery, thereby extending the global period for surgery beyond that prescribed by the Centers for Medicare & Medicaid Services (CMS).

Resolution: Aetna changed its payment practices to match CMS practices. Beginning Jan. 1, 2007, physicians can resubmit claims for dates of service between Jan. 1, 2005, and Feb. 11, 2006, when the policy changed. 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 E&M code appended with a -25 modifier, as required by the settlement.


  • Aetna fixed the system to pay the affected codes, effective Nov. 12, 2006.
  • 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 will reprocess claims with these codes with dates of service back to May 1, 2006.  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 Web site to make it more user-friendly and transparent for physician offices.

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 the settlement. However, because Medicare and some other payers do not require the -25 modifier 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 -24 dispute.
  • Aetna removed the edit entirely effective Aug .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 Feb. 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 the settlement.


  • 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 Jan. 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 not been previously submitted.  Aetna's agreement to allow physicians to file these claims went further than required by the settlement.
  • Physicians submitting add-on claims collected more than $6 million, demonstrating the value of the compliance process.

Contract Dispute

Issue: Aetna's physician contracts did not contain all the provisions required by the settlement.

Resolution: Aetna sent a contract addendum to all contracted physicians containing the language required by the settlement and clarifying certain contract terms. It also extended the term of the most important terms of the settlement 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. 

All Products

Issue: A physician practice which sought to withdraw from Aetna's captivated product was terminated as a participating provider from all other products, a violation of the settlement

Resolution : The practice was reinstated and claims were reprocessed.

Overpayment Recovery

Issue: Aetna sought recovery for overpayments to several practices after 24 months. This is a violation of the settlement, which allows overpayment recovery after 24 months only if there is "reasonable suspicion of fraud." 

Resolution: Successful resolutions vary by practice because the facts vary by practice.

For information on settlements with other defendants, log on to   

Last Updated On

March 13, 2011

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