Is anyone else noticing Aetna E/M claims being randomly downcoded without any justification? We have had many 99214 downcoded to 99213, even though the MDM supported the 99214. If you are experiencing this and likely appealing, have you had any success in getting these decisions overturned?
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Wiki Aetna downcoding of E/M claims
- Thread starter kdaugherty@tdmso.com
- Start date
gkral
New
We were stuck in their "down coding program". From what I understood, after talking with many Aetna reps, they put some docs in this program as they are flagged for over coding (even though they don't review the record before making the decision) and it's almost impossible to get them out of the program. We found success appealing with notes. It's been very frustrating.
justkissed1
New
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- 5
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- 0
We are having major issues with Aetna downcoding our ER claims and only using a remark code and not a denial code. A separate issue is they are not paying our contracted rates and low paying. There has got to be some type of class action law suit to stop this?
jkyles
True Blue
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- 996
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Hi there, for contract violations I recommend contacting your state's insurance regulator.
It's happening with our claims too, most 99214/99215 being down oded to 99213 without request for records, started at the end of March. It's very frustrating to have to appeal them all... I would rather have insurance send a notification for batch audit, which would make more sense, than outomatically downcoing on the payment eob without any pre-review. Luckily our system flags if there is a discrepancy between code billed and code processed on eob, but not everyone may be able to catch the issue