Aetna recently announced that it is rolling out a national protocol under which it will be reviewing both physician and hospital emergency department claims that include Level 4 or 5 evaluation and management (E&M) codes, and after that review, "may adjust your payment if the claim details don't support the level of service billed." The process will apply to both fully insured and self-funded benefit plans, and will go into effect on July 8, 2024. When other plans have adopted this kind of process, it has resulted in significant reductions in payments to providers. Aetna does not provide any detail about the standards that it will use to determine whether claim details support the level of service billed, but we anticipate that Aetna may use improper criteria, including without limitation, the ultimate diagnosis of the patient's condition.
Your provider agreement may allow you to object to this change in Aetna's processes. You may also want to pursue other dispute resolution procedures to ensure that this process is not applied to your claims.
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