Aetna last week settled another RICO compliance dispute and agreed to start paying physicians for evaluation and management (E&M) services and other non-E&M services provided to the same patient on the same day when billed with modifier 25. Despite agreeing in the settlement to pay these codes, many such claims were being denied.

CMA has posted on its website a complete list of the 200-plus non-E&M service procedure codes affected by this agreement. Aetna has agreed to begin paying these codes immediately. The plan will also automatically reprocess all improperly rejected claims with dates of service on or after July 1, 2004. Physicians who filed disputes on this issue will be paid for rejected claims dating back to May 21, 2003 (the date of the original settlement agreement). This is worth at least $3 million a year in additional payments to physicians.

Aetna has also agreed to participate on a task force with state medical society representatives to revise its other payment policies that improperly deny physicians payment. These policy changes—worth a minimum of $1.7 million a year in additional payments to physicians—will apply to claims with dates of service after May 1, 2006. Aetna will automatically reprocess relevant claims as necessary.

This compliance dispute is different and separate from last month’s announcement that Aetna had agreed to pay physicians for problem-oriented E&M services provided during a preventive services visit, when billed with modifier 25.

For more information on CMA's RICO lawsuit, including the commitments made by the six settling health plans and information on how to file a dispute if you believe a plan is not in compliance with its settlement terms, see the RICO Resource Center

Contact: CMA’s legal information line, 415/882-5144 or legalinfo@cmanet.org.