Recently, Aetna Insurance has significantly increased the frequency with which it is downcoding Evaluation & Management (E&M) visits for some of the claims being submitted by Rocky Run prior to their evaluating the basis for the claims. This has a material impact on the practice and patients. Reviewing claims for proper coding is a very positive activity, and we encourage Aetna to do so, However, it appears they are regularly downcoding without applying the evidence-based approach which is the industry standard and part of the guidelines we all follow.
It is our reading that relevant Virginia statute prohibits a carrier, intermediary, administrator, or representative of a carrier from downcoding a claim unless the decision to downcode reflects correct coding standards and considers all relevant patient data from the billing provider in making the determination.
In a letter to Aetna requesting that they stop downcoding prior to have complete data, we wrote “Aetna bears the burden of explaining the basis for any such downcoding. We offer access to our notes and documents so that Aetna may review the necessary information that would justify coding and downcoding. Thus far, Aetna has not, prior to downcoding, requested the information needed to meet this burden. Aetna making a decision to downcode does not shift the burden to RRFM to disprove coding changes.” We were disappointed with Aetna’s response as it did not resolve our root concerns.
The Rocky Run Process
When a patient has a visit, the provider and medical support team engage in many activities, as needed.
- Reviewing past chart notes / medical history, information from other specialists / sources, and past labs or imaging reports;
- Reviewing available medication history;
- Discussing current issues or concerns that may exist;
- Documenting visit details and recommendations;
- Ordering lab tests, injections, or other procedures;
- Initiating needed referrals;
- Completing needed patient documents;
- Creating a follow up plan;
- Completing and signing off on a visit note; and,
- Ensuring proper ICD-10 (diagnosis) and CPT (charge) codes are applied, according to CMS/AMA standards.
Subsequently, prior to sending the claim, our billing and coding team reviews the coding to verify that it matches the criteria established by CMS/AMA. Discrepancies or concerns are addressed prior to the claim being sent. Each claim is coded based on the merits of the visit related information, not on statistics or relativity to other claims.
Aetna’s Actions
Aetna generally processes and pays claims in a timely fashion. If a claim is rejected at the clearinghouse or by an insurer’s automated system, we get a daily report and address the rejection. If a claim is processed and a line is denied or fully disallowed, our billing team reviews, and if needed provides additional information to the insurer for reevaluation. In rare cases where there is “confusion” caused by a claim, insurers contact our billing team for documentation support or to address the specific question. The concern herein addressed is specific to Aetna downcoding E&M visits without first requesting and considering relevant claim /visit information.
Actions Taken and Potential Impact to Patient’s
Rocky Run is in the process of appealing the Aetna downcodes and providing necessary information to support original codes submitted. It is our belief that most, if not all, downcoded claims will be “overturned” through this process. We consider a vast majority of the claims as very straightforward (a level 4 visit addressing multiple chronic conditions, reviewing past notes and labs, ordering appropriate lab panels, managing and prescribing medications) and we wonder why documentation is even needed when Aetna already has much of this information.
The impacts are significant. In claims where this is occurring, Rocky Run’s payments are being reduced by $45 to $105 per visit. The actual cost of recovery is another $10-$20 on the front end with another $10+ to adjust the payments and patient accounts when proper payment comes through. It is Rocky Run’s goal to address direct patient needs as a priority. Each instance where this is happening takes 10-15 minutes of support team time which otherwise could be focused on patient needs and responsiveness.
There are also two critical direct impacts to you, our patient.
- As many of you have deductibles or co-insurance, this can cause challenges and confusion. For example, when a lower code is reimbursed and applies to your deductible, we invoice that amount and you pay it. At a later date, when the payment is reissued to reflect the (original) correct code, you may owe an additional amount. We have requested (no response yet) Aetna reimburse us, and regardless of the patient’s plan, that they pay the entire difference, and not move that to patient responsibility.
- When you receive your EOB (Explanation of Benefits) and Aetna has lowered the E&M code, they indicate “Remarks: 1 – These service codes reflect the submitted codes. The service codes directly below the shaded lines indicate the service codes utilized for payment based upon our claim policies and rules. [998] 2 – 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]”. The fact they indicate that their payment more accurately reflects a proper E&M code would necessitate their review of the services provided when that review, to the best of our knowledge, never occurred. As aforementioned Aetna deciding to downcode should not shift the burden for us to disprove their coding changes.
Conclusion
Rocky Run believes that meeting both legal and ethical standards are critical. While our communication with Aetna leads us to believe they share a similar values, it appears that their implementation of a key process may not stand up to that principle. We hold Aetna in high regard and will continue to work with them to address this situation in the most effective manner.