LEGAL RESOURCES
Major Victory with Successful Resolution of a Compliance Dispute against Aetna, Inc. involving Modifier 25
MSSNY is pleased to report that physicians, MSSNY and other Signatory Medical Societies (medical societies that signed the Settlement) involved in the HMO Class Action Settlements have won a major victory with the successful resolution of a Compliance Dispute against Aetna, Inc. involving Modifier 25. Among the terms of the Class Action Settlement Agreement with Aetna, section 7.20(b)(iii) provides that if a bill contains a CPT code for performance of an evaluation and management CPT code appended with a Modifier 25 and CPT code for performance of a non-evaluation and management service procedure code, both codes will be recognized and eligible for payment unless the clinical information indicates that use of Modifier 25 was inappropriate or Aetna has disclosed pursuant to section 7.8(c)(iii) of the Settlement Agreement that such services are not appropriately reported together. In the compliance dispute, numerous class physicians alleged systemic failure on the part of Aetna to pay for certain non-evaluation and management service procedure codes when billed with an evaluation and management code appended with a Modifier 25. After a lengthy mediation process provided under the Settlement Agreement, Aetna agreed to a Mediation Consent Order that contains terms favorable to physicians. Among these terms:
- Aetna will pay those class physicians who filed Modifier 25 Disputes pending as of May 1, 2006 for all codes listed in Appendix A billed in conjunction with an evaluation and management code appended with a 25 Modifier back to and including May 21, 2003.
- Aetna has agreed to reprocess all claims for physicians submitting the codes contained in Appendix A when billed in conjunction with an evaluation and management code appended with a 25 Modifier with dates of service of July 1, 2004 through April 30, 2006, (“Back Claims”) and will do so no later than October 1, 2006. Aetna will issue an Explanation of Benefits for each such claim detailing the payments and the rationale for each determination.
- Aetna has agreed to the establishment of a “Strike Force” with representatives from Signatory Medical Societies and physician members of the Physician Advisory Committee to review and make recommendations to change Aetna payment policies.
- Aetna has agreed to create a Task Force with physician representation to recommend changes to Aetna’s Provider website to make the website more user-friendly for physicians and to assure that Aetna’s payment policies are as transparent to physician practices as reasonably possible.
- Aetna has committed to make changes to its claims payment software to allow payment of the codes listed in Appendix A when billed with an evaluation and management code appended with a Modifier 25 as soon as practicable. In the interim, Aetna will work with the Compliance Dispute Facilitator and representatives of Signatory Medical Societies to identify a process by which Aetna will pay physicians who submit claims containing codes listed on Appendix A when billed with an evaluation and management code appended with a 25 Modifier from May 1, 2006 until the system changes have been implemented.
MSSNY’s participation with other medical societies in the HMO Class Action Settlements continues to result in meaningful benefits to physicians and their patients. Thanks are also extended to the AMA for its support.
For more information on the HMO Class Action Settlement, see www.hmosettlements.com and MSSNY’s Class Action Settlement webpage. MSSNY’s website includes the “HMO Settlement Enforcement Tool Kit” which features a step-by-step guide to bring a Compliance Dispute for class physicians who believe that the Health Plan is not in compliance with a term of the Settlement Agreement.
CODES TO BE REPROCESSED WHEN BILLED WITH AN EVALUATION AND MANAGEMENT CODE APPENDED WITH A 25 MODIF
