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08/30/2019
Aetna Responds to ANJC DOBI Complaint

In June of this year, the ANJC filed a complaint with DOBI against Aetna for a number of processing issues. 
ANJC Leadership met with DOBI Commissioner Marlene Caride and her team in follow up to our complaint in July.  Attendees included Dr. Jordan Kovacs, board president; Amy Boright Porchetta, executive director; Dr. Michael Goione, insurance consultant; Jeff Randolph, general counsel; Jon Bombardieri, government affairs counsel; and Matt Minnella, director of insurance and regulatory affairs.
The complaint was comprised of several distinct issues.  Please see below to get an update on each:
Triad Healthcare – Processing Errors
Aetna has acknowledged that the transition from Triad to NIA resulted in claims processing errors and delays.  On July 5th, Aetna implemented a new system and claims are no longer being mis-routed.  All impacted claims will be reprocessed by the end of this month; claims payments will include late claim interest where applicable.
Pre-Authorization Processing Errors:
NIA System Error – NIA acknowledges a system issue that impacted transmissions of authorizations from NIA to Aetna which caused some claims to inappropriately deny for no reason.  This was resolved on July 3, 2019.  All claims that were inappropriately denied for no authorization from January 1 – May 31, 2019 have been submitted for reprocessing.  Aetna will identify claims from June 1 – July 31 and reprocess later in the month.  Reprocessed claims will include late claims interest, if applicable.
NIA Website/Portal- Claims that were denied for no authorization after the NIA website/portal indicated that no authorization was required will be reprocessed and will include late claim interest, if applicable.  Aetna believes this error was due to Aetna claims examiners incorrectly denying claims due to not following processing rules.  Furthermore, Aetna has confirmed to DOBI that they have provided training to their claims processors and examiners; internal documentation has been updated as well.  It is believe that these are limited to state employees only.
Aetna Physical Medicine Utilization Review Matrix
Providers receiving denials who had appropriately billed procedure codes that were part of a the allowable billing code for the parent code group will have their claims reprocessed; late claim interest will be included in these payments, if applicable.  Aetna has corrected the data table as well.
Benefit Accumulators
The issue that was causing therapies to be double counted, thus resulting in patients appearing to have reached the limit on their treatments faster than they had and resulted in denied claims, has been resolved.  Aetna is working to correct the claims that were denied and is working on a permanent fix to this issue.  Having an authorization on file would initiate that the member did not exceed their authorized number of visits and Aetna will reprocess the claim, including late claim interest, if applicable.
Incorrect Counting of Pre-Authorized Visits
Aetna has identified another system processing error whereas therapy units are being miscounted.  Aetna is currently addressing these claims via monthly reports; reprocessing claims which will include late claim interest, when applicable.  Aetna expects to have a permanent fix in place for this in November.
Denials of CPT Codes with -25 and -59 Modifiers
In November 2018, Aetna implemented a new claim editing software to verify billing of -25 and -59 modifiers.  The software considered patient claim history and diagnosis codes; in some cases, a clinical nurse coder reviewed the information to determine if the modifier should be allowed.  Aetna has stopped using the claim editing software to review these modifiers effective August 1, 2109.  Claims will be reprocessed, if needed.
Please note that Aetna has indicated to DOBI that providers do not need to submit anything for claims to be reprocessed.