Aetna Settlement Information

The following documents will help you understand your rights under the Aetna settlement agreement.

Important Message Regarding Aetna's Payment Policy for Urinalysis Dipstick and Pulse Oximetry When Billed with Evaluation and Management Codes (E/Ms) Appended with Modifier 25.

Important Message Regarding Aetna’s Payment Policy for Modifier -57 for Evaluation and Management (E/M) Services at Which Decision for Surgery Is Made

Aetna has reached an agreement with state medical societies to pay resubmitted claims for E/M visits billed with a Modifier -57 (indicating that the decision for surgery was made during the visit) when billed with major (global 90 day) procedures, for dates of service from January 1, 2005 through February 11, 2006.  After seeking input from medical societies and the independent Physician Advisory Board, Aetna decided to change its policy and began paying these claims effective February 12, 2006. Physicians can resubmit previously denied claims since January 1, 2005 beginning January 1, through April 30, 2007.

When May Claims be Resubmitted?
The resubmission period is January 1, 2007 through April 30, 2007. 

Spreadsheet for resubmitting previously denied Evaluation and Management codes when billed with Modifier 57

Online information will be available in December 2006
Aetna will post key information, including detailed instructions and forms that are required to ensure timely and accurate processing of the resubmitted claims, on their Web site. Information and forms will also be posted on www.aetna.com in December 2006.

Pertinent information:

Questions about the settlement may be directed to Whatley Drake & Kallas, L.L.C., at (866) 809-8003.

Compliance dispute facilitator (CDF)
Physicians may consider filing a “compliance dispute” if prohibited clauses are contained in a health plan’s contract or if the health plan fails to adhere to the terms of its settlement.  After the dispute is deemed valid by the CDF, the CDF will act as the physician’s representative unless the physician or Signatory Medical Society, acting on the physician’s behalf, elects to employ separate counsel.  Below is the contact information for the Aetna CDF:

Deborah J. Winegard
c/o Doffermyre Shields Canfield Knowles and Devine
1355 Peachtree St., Suite 1600
Atlanta, GA 30309
Phone:  (404) 881-8900
Fax: (404) 881-3007

To learn more about foundations created by the settlements, please go to the Physicians Foundation Web site.

How the Aetna Settlement Agreement helps the physician practice flyer (prepared by AMA) contains a summary of the key business practices mandated in the Aetna settlement. Since contracts provided by Aetna to physicians in its provider network must conform to the settlement, physicians are encouraged to review their contracts to ensure they are receiving available protections.

For Aetna dispute procedures, click on the links below:

• Aetna Compliance Dispute Resolution and Retroactive Medical Payment Policies
• Aetna Dispute Category List
• Aetna Compliance Dispute Procedure
• Aetna External Billing Dispute Procedure

For the Aetna Compliance Dispute Claim Form, click on the link below:

• Aetna Compliance Dispute Claim Form

This summary has been prepared by the American Medical Association (AMA) Private Sector Advocacy unit from information provided to the AMA.

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