AOA asks Aetna to end ‘potentially illegal actions’ on downcoding claims
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The American Optometric Association voiced its concern to Aetna regarding “inappropriate decisions” made on claims submitted by some physicians, including optometrists.
AOA President Barbara L. Horn, OD, wrote a letter to the president of Aetna regarding the company’s new, nationwide program to automatically downcode certain claims.
“The AOA is concerned about improper and potentially illegal actions recently undertaken by Aetna,” Horn wrote.
According to a press release from the AOA, the association notified members in December of Aetna’s decision to automatically downcode claims submitted for office visits including evaluation and management codes. This would occur when the plan finds an “apparent overcode rate of 50% or higher” and would process without reviewing doctor records for such visits.
“This appears to be in violation of HIPAA, a variety of state laws related to fair, accurate and timely processing of claims, and Aetna’s contracts with patients and physicians alike,” Horn wrote. “Specifically, Aetna is arbitrarily replacing the code submitted by the doctor that describes the service provided with a different code representing a lower level of service. It is inappropriate for any insurer to make these decisions using an algorithm based on the doctor rather than a review of the patient’s charts.
“This bad faith negatively impacts patients. We ask you to end this unjustified practice immediately,” Horn added.
Doctors who find their claims downcoded may appeal through Aetna’s internal process. The company informed the AOA that doctors with the most downcoded claims overturned by appeal will be considered for removal from the program.
The AOA also noted a potential violation of Section 2706 of the U.S. Public Health Service Act, which prohibits discrimination in coverage and network participation.
“Aetna is not contracting directly with doctors of optometry. Instead, Aetna requires doctors of optometry to contract with EyeMed,” Horn wrote. “This discriminatory practice forces doctors of optometry to meet the credentialing requirements of EyeMed, rather than the conditions of participation for Aetna, even though Aetna credentials other health care professionals who provide the same services.”
Horn explained in her letter that many optometrists do not fit EyeMed’s model of retail optometry or may be in competition with EyeMed’s commercial interests, leading to denied access.
“Meanwhile, medical doctors contract directly with Aetna, allowing ophthalmologists to freely credential with the medical plan without being subject to EyeMed’s self-serving network restrictions,” Horn wrote. – by Talitha Bennett
Disclosures: Horn is the president of the American Optometric Association.
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