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.