we have received a few letters from aetna wanted to recoup the reason they said. "This claim was calculated incorrectly based on the pricing of modifier AS." for a claim that was finalized and paid on august of 2023, does any one knows how we can stop them from recoupment?
-
If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below..
Wiki RECOUPMENTS
- Thread starter irisromero93@gmail.com
- Start date
CBLENNIE
True Blue
Are you contracted with Aetna? If so, you need to review the contract to determine what the terms are for adjusting claims to recoup what Aetna believes is an overpayment. If you are not contracted with Aetna it would depend on the patient's insurance policy/plan/certificate of coverage and what it states about these types of adjustments.
we are out of network and the claims are for an assistant surgeon, we are in texas. and overpayment reason is that they calculated incorrectly based on the pricing of modifier 80 for the cpt billed. Do you know when does the senate bill 418 come in place or when can we use it to dispute the recoupment
CBLENNIE
True Blue
Based on the information provided I can't answer your question about SB 418 but the Texas Department of Insurance has a great flow chart on determining if the Prompt Pay Guidelines apply to a claim, which I've linked here. The language of SB 418 has a section on repayment of overpayments, and it looks like the time frame for requesting an overpayment is 180 days from when the payment was issued.
However, all of this information may be pointless if the patient's plan is an employer self-funded plan that is governed by ERISA or a Medicare Advantage plan, which are not subject to state regulations.
So, I don't have an actual answer to your question because there are still too many factors that determine if Aetna is within its rights to recoup a payment made 13 months ago.
However, all of this information may be pointless if the patient's plan is an employer self-funded plan that is governed by ERISA or a Medicare Advantage plan, which are not subject to state regulations.
So, I don't have an actual answer to your question because there are still too many factors that determine if Aetna is within its rights to recoup a payment made 13 months ago.