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Aetna requesting medical documentation.
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Re: Aetna requesting medical documentation.
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Steve Verno
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Oct 15 10 6:01 PM
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A provider contract may have language that states the provider agrees to the carrier's policies and procedures. If this is so, and this is their policy, then the provider may have agreed to this. There is usually a reason they are asking for the documentation to support what was billed and that is something we dont know. This situation may also be something that may need attorney intervention. Even though the provider contract may not state you have to send in the records when requested, applicable State or Federal law may say so. Again, there is usually a reason why they would do this, but we dont know the reason. It could be a preventive measure to weed out possible fraud or abuse. Re-reading the original post, Aetna did send out a notice regarding their policy for certain services. So, this should not be something unknown as they did state they wanted charts on these specific services.
Now, lets do a short fairy tale. Say Dr A is contracted with ABC Company. ABC sends out a notice to all doctors of a specialty in Frostbite Falls Minnisota and the notice says if you provide XXXXXX as a service, you must submit the medical record with your claim. Yes, Dr A's contract may not say anything about this, but ABC has announced their new policy, so as a par provider, it is best to try to comply with this policy. Frostbite Falls has a history of receiving fraudulent claims from providers of a specific specialty, hence the caution on paying claims for those spedific services and asking for charts to ensure there is no fraud or abuse (Understand no one is making an accusation of fraud or abuse taking place). Now, you have Drs. Boris and Natasha are submitting claims for XXXXX in Frostbite Falls, The incidents of XXXXX being provided has risen. Were there were maybe 10-20 of these performed every month. Now 10,000 are being performed. The cost to ABC has also risen to more than #20,000,000 in claims, so they hire a company to look into the rise of this service being provided by this specialty. Drs Boris and Natasha have no clinic. Their office is a post office box. They drive around neighborhoods looking for ABC patients. They get the insurance info and using a forum, they asked, if we provide XXXXX, what codes do we use? The forum says you use & CPT Code and # diagnosis. BINGO, you have a nice scam taking place. Dr A is an innocent bystander caught up in this sad situation. Now, he has to send medical records with all his claims and it takes 6-8 months or longer to get paid. But, Dr A isnt doing anything wrong. After time, it is proven Dr A is a good guy and everyone lives happily ever after except for Drs Boris and Natasha. They get caught, are sent to Jail and when they get out they go on the talk show circuit. The End!
I cannot speak for Aetna. To get paid, as a par provider, it may help get the claims paid by submitting what they request. That is what we did with all workers comp claims. We also attached a w-9 form with every claim. Yes, it was a pain, but it got the claims paid. Your doctor may wish to meet with Aetna and see what's happening. But, if they want the chart, I would send it.
Last Edited By:
Steve Verno
Oct 16 10 1:32 AM. Edited 2 times.
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Medical Billing & Coding Education from the MAB
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Management Advice and Training
Questions Asked More Than Once
Help Wanted - Billing and Coding
Non Billing Talk
The Venting Area (Clean posts please)
Medical Coding and Billing News
Fraud and Abuse
Health Insurance - Provider Contracting
ERISA
Tricare
Workers' Compensation
General Medical Billing Questions
Appeals
Accounts Receivables (A/R)
Refunds
Auto Accident Issues
Medisoft Technical Support
Medical Software Technical Support Questions Other than Medisoft. No Investigation Questions!
General Medical Coding Forum
CPT Coding Questions
HCPCS Coding Questions
ICD-9-CM Coding Questions
Evaluation & Management Coding Questions
Acupuncture Billing and Coding
Ambulance Coding and Billing
Cardiology Coding and Billing
Chiropractic Coding and Billing
Dental Billing and Coding
DME Coding and Billing
Emergency Department Coding and Billing
Family Practice Coding and Billing
Hospital Inpatient and Outpatient Coding
Hospital Billing, Appeals and Collections
Internal Medicine Coding and Billing
Laboratory Coding and Billing
Ophthalmology Coding and Billing
OB-GYN Coding and Billing
Pain Management Coding and Billing
Pediatric Coding and Billing
Podiatry Coding and Billing
Physical Therapy Coding and Billing
Psychiatry Coding and Billing
Radiology Coding and Billing
Surgery Coding and Billing
Neurology Coding and Billing
Urgent Care Coding and Billing
Provider Compliance
Billing Center Compliance
HIPAA
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