Practice Management Alert

Help Keep Aetna Honest By Filing Dispute Forms

If your medical office was part of the Managed Care Litigation suit, you should be able to collect your settlement soon, if you have not already.

The details: More than 900,000 physicians and state and county medical societies sued insurers including Aetna, CIGNA, Health Net Inc., Prudential, Anthem/Wellpoint and Humana Inc. The suit addressed several issues with Aetna's policies, such as
improper bundling of codes, denials of claims despite proof of medical necessity, and improper guidelines for filing claims with modifiers.

How much? There are different settlement amounts for each insurer, but Aetna settled for $100 million. This works out to about $200 for each doctor named in the class-action suit, says Barbara Cobuzzi, MBA, CPC, CPC-H, CHBME, of CRN Healthcare Solutions in Tinton Falls, N.J.

-But this settlement wasn't really about the $200. It was about the fact that Aetna had to change payment practices and change its method of giving info to physicians,- she says.

-These changes are expected to result in increased predictability and speed of claims payment, creating value for physicians by reducing time-consuming and costly administrative burdens,- states the Web site for the HMO Settlements Plaintiffs- Counsel.

Make Sure Aetna Has CPBs to Back Up Denials

While medical offices that participated in the class-action suit will not scoff at the $200 settlement, the real victory came in the accountability department, Cobuzzi says.
 
As a result of the settlement, Aetna must now post its payment policies online in the form of clinical policy bulletins (CPBs).
 
-These act as local coverage determinations (LCDs) do for Medicare,- Cobuzzi says. -If Aetna is denying a service or procedure, it must explain why in a CPB.- Before the settlement, Aetna did not have to post its policies, creating confusion and frustration for billers trying to figure out the insurer's guidelines.

Check it out: For entry into Aetna's CPB files, go to www.aetna.com/about/cov_det_policies.html.

If Aetna does not list a CPB for a service or procedure, they cannot legally deny it. 

Further, if Aetna denies a service or procedure and you think it was an error, you now have a forum for your complaint: the Aetna Billing Dispute Resolution Form.

-If Aetna creates an unreasonable CPB, this is the place to settle the dispute,- Cobuzzi says.

Get your copy: For a copy of the dispute form, go online to www.hmosettlements.com/forms/billingform.aspx. -This is a printable form and must be signed by the performing physician to be valid. It may cost a bit, but it's worth it,- Cobuzzi says.

According to the dispute form, it costs $50 to file a dispute between $500 and $1,000; for disputes exceeding 1,000, you-ll have to pay $50 plus 5 percent of any settlement total.

Try this: To file a billing dispute with Aetna, your must have at least $500 worth of disputed claims within one year. For example, you have a $200 billing dispute in March, a $100 dispute in June, and a $300 dispute in December. At that point, you have $600 in disputed claims, and you can file a billing dispute with Aetna. (Note: You must file the dispute form within 90 days of the last disputed claim.)

Take disputes seriously: Experts recommend that medical offices file formal billing disputes whenever possible. If Aetna gets enough complaints about one of its billing practices, it may be forced to change the policy. Plus, Aetna will know providers are watching payment practices if it receives regular billing dispute forms.

-It's like driving on the highway. If you know there are speed traps, you-ll be more honest in your driving,- Cobuzzi says. By filing the complaint forms when appropriate, medical offices are acting as -speed traps,- she says.

But if few people file complaints, insurers -know they are not being watched, and the effectiveness of the class-action lawsuit is thrown away,- she says.