Aetna Denials for 97140 & Chiropractic Adjustments (Part 2)

As I mentioned in my previous blog post Aetna Denials For Manual Therapy (97140) and Chiropractic Adjustments, it appears that Aetna is up to no good again in terms of denying claims for chiropractic adjustments and manual therapy (97140) services performed on the same day.

For those of you who read the post, you will recall that I did not point the finger entirely at Aetna and mentioned the fact that there are four distinct criteria that need to be met to get your claims paid if your are performing these two services on the same day.  Generally speaking, if you apply those criteria, you should anticipate payment; if you don’t, it’s your fault – you did it wrong!

Why Playing By The Rules Won’t Work for Aetna in 2013

Believe it or not, Aetna could care less whether you play by the rules of CPT coding, diagnosis pointing or correct documentation.

According to a recent policy change, they are just not going to pay for chiropractic manipulative therapy (CMT) and Manual Therapy (97140) on the same day – no matter what!

Yes, you read that right!  The December issue of Aetna’s Newsletter of the Ridiculous Policy Changes (not it’s official name – but click link to read and weep) spells it out clearly.  If you don’t want to read their trash, here it is:

  • Effective March 2013, Aetna will not pay for CMT and 97140 on the same day.

Doesn’t matter if you use modifiers correctly, complete your claim form properly, document everything in gory detail and include a 5 spot with your claim – they ain’t paying. No dice.  Tough noogies.  Cerrado.  Over and out.

And yes, by the way, even though the newsletter is a December issue, Aetna is very efficient. Denials for these two services have started already! You have to call or write an appeal to get these early-bird denials paid and then Aetna will tell you that starting next year, it’s over baby!

How Can Aetna Get Away With This?  Do Chiropractors Have Any Options?

Most of the emails that I have been receiving have irately asked the above two questions.  Here are my answers and remember, I don’t make the rules – I am just the sicko who is standing here, unarmed, reporting this bad news to you.

Q: Is this legal for Aetna to do this?

A: I’m no attorney, but, unfortunately it’s not really a legal issue.  Welcome to the world of “proprietary”edits.  This is better translated as “the insurance company has the right to make up their own rules.

Q:  What can chiropractors do about it?

A:  The answer depends.  You have several options, outlined below:

If you are contracted with Aetna

  • you must adhere to the policy change (agree not to be paid) or get out of their network
  • your service will appear on the EOB as a denial — $0 under the allowable and $0 under portion for patient responsibility
  • you DO have the option of informing your patient beforehand that Aetna will not pay for the service and giving them a Notice of Non-Covered services (an ABN type waiver which informs the patient that the insurance won’t pay).  Have the patient sign the waiver/notice and agree to pay you out of pocket for the service. When you bill for the service, it will still result in a denial (as above) but you now have the ability to collect for that service from the patient. See our ebooks section for NOTICE OF NON-COVERED SERVICES SAMPLES that you may purchase and modify to use for this purpose.

If you are not contracted with Aetna

  • they still won’t pay you but you may charge the patient for the balance

What all chiropractors can do about the Aetna mess

  • Complain, protest, kick, whine and scream that Aetna is making up their own rules,
  • Sue Aetna for applying discriminatory practices.  After all, who else uses a CMT code but chiropractors?  it’s a very crafty and convenient trick for Aetna to bypass CPT code rules, make up their own and have it single-handedly affect only one class of practitioner.
  • Get your state and national associations involved (in reality, one DC isn’t going to have enough $ to sue Aetna by themselves or make enough noise to get them to change their mind)
  • Pray for my safety or at least buy a few products! If Aetna decides to chase my down for airing their dirty laundry, I’m going to need some cash to hire a bodyguard or to start building an impenetrable fortress on an unknown island.

PERHAPS THE BIGGEST THING CHIROPRACTORS CAN DO ABOUT THE AETNA MESS…

  • Email your friends, get on Facebook, Tweet, Share this (and my previous post) with your friends! Our profession needs to know about this before it really hits the fan in 2013, else we will have even more confused and unhappy campers who aren’t being paid for their services!!!
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