| Physicians have scored a major victory using the dispute resolution mechanism outlined in the settlement that Aetna, Inc., (Aetna) agreed to enter to resolve the class action MDL lawsuit brought by physicians and state and county medical societies. The dispute in question related to Aetna’s lack of recognition for payment of services reported with a CPT® Modifier 25. Last week, the Compliance Dispute Officer entered a mediation consent order requiring Aetna to, among other things, pay for certain claims appended with a CPT Modifier 25 that were previously denied. The order applies to claims with dates of service as far back as May 2003. Payments due to physicians collectively are estimated to be between $6 million to $20 million, which could increase due to a 6% interest penalty attached to any claims that remain unpaid by October 1, 2006. Aetna is also required to change its claim payment software “as soon as practicable” to allow for payment of certain claims with CPT Modifier 25 appended. Such administrative and other changes will cost Aetna at least an additional $1.7 million. The decision sends a clear message to all other defendants who have settled in the MDL litigation that physicians are intent on ensuring health plans comply with their settlements or face expensive legal expenses that far exceed any potential savings from exercising questionable business practices.
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