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Modifier–25 Dispute with Aetna Resolved

As part of MAG's landmark settlement with Aetna in the MDL RICO litigation, Aetna was required to pay physicians for both a procedure code and an evaluation and management code, appended with a Modifier–25 when billed together. Several physician practices and two state medical societies brought compliance disputes alleging that, in many cases, Aetna was not paying physicians for procedures billed with an E&M code, appended with a Modifier–25. Earlier this month the issue was successfully resolved using the mediation process in the settlement agreement. The following provisions were established:

• Aetna will pay all disputants back to May 21, 2003 (the effective date of the settlement.)
• Aetna will rework claims of other physicians with Modifier-25 dispute claims back to July 1, 2004 for an agreed upon set of codes. If a payment is not made by Oct. 1, Aetna will pay 6 percent in additional penalties.
• Aetna will create a mechanism to pay physicians correctly in the interim until the system is fixed.
• A joint Strike Force has been set up to review other codes in question but which are on various Aetna do-not-pay lists. MAG member Dr. Robert Harrison has volunteered to serve on this committee. Aetna has agreed to make payment policy changes worth at least $1.7 million annually as a result of recommendations of the Strike Force. Aetna will reprocess claims with these additional codes.
• Aetna will pay $200,000 in expenses for the Strike Force.
• Another Task Force will be assembled to make recommendations for a more user-friendly provider Web site.

Although Aetna has a small market presence in Georgia, the settlement is a success for physicians in the ongoing MDL RICO suit and in future compliance disputes. This dispute involved both Aetna's commitment to follow CPT and to modify its claims processing systems in accordance with the settlements terms.