Becker's Hospital Review

16 CFO / FINANCE Aetna draws criticism for automatic down- codes By Morgan Haefner P roviders are concerned a national policy from Aetna involving evaluation and management services will result in inappropriate down-codes. Under the policy, Aetna will automatically down- code claims submitted for office visits or certain modifiers when the insurer finds an "apparent over- code rate of 50 percent or higher." e policy con- cerns office visits with the 99000 series of evaluation and management codes and the 92000 series of oph- thalmologic examination codes, as well as modifiers 25 and 59, the American Optometric Association said in an advocacy post. AOA said Aetna didn't explain how an overcoding determination is made under the insurer's algorithm, whether with or without medical record reviews. "e AOA believes it is inappropriate to downcode such claims without first reviewing actual medical records and questions whether it complies with HI- PAA; a variety of state laws related to fair, accurate and timely processing of claims; and Aetna's con- tracts with patients and physicians alike," the associ- ation said on its advocacy page. Physicians can appeal down-coded claims through Aetna's internal process. In a statement to Becker's Hospital Review, Aetna ex- plained why it implemented the policy: "We periodically review our claims data for correct coding and to implement programs that support nationally recognized and accepted coding policies and practices. rough a recent review, we identi- fied healthcare providers across several specialties who are significant outliers with respect to coding practices. While we recognize that healthcare pro- viders undoubtedly may have complex medical cases that are unique to their practice, this result is much higher than the average for physicians across most specialties. "For this small, targeted group of healthcare provid- ers, we will review their claims against [American Medical Association] and CMS coding guidelines. Based on that review, we may potentially adjust their payments if the information on the claim is not supported by the level of service documented in the medical record." n Idaho anesthesia provider lays off 53 workers: 'Our revenue is about to trickle to nothing' By Alia Paavola C iting an expected revenue loss from the COVID-19 pandemic, Boise Anesthesia Physician Associates laid off 53 nurse anes- thetists March 18, according to The Idaho Statesman. The Idaho anesthesia provider said it made the decision after deter- mining it would not make enough money to support its staff. The Boise Anesthesia practice works under contract for Saint Alphon- sus Health System in Boise, which means its physicians and nurse anesthetists aren't directly employed by the hospital. To generate revenue, the practice relies on the hospital conducting surgeries and other elective procedures. But Saint Alphonsus has cut back on elective procedures and like- ly will cancel all of them soon, following similar moves by other U.S. health systems as a result of the novel coronavirus pandemic. "We know that our revenue is about to trickle to nothing," Nate Poul- son, MD, chief executive of Boise Anesthesia Physician Associates, told the publication. Dr. Poulson said he is working to help the affected nurses find jobs, adding that hospitals in the area will need nursing staff at all levels to combat the novel coronavirus. "The people that work for our company are tremendously talented people," he told the publication. "This story will not just apply to us. This is going to apply to a lot of different providers." n CommonSpirit suspends patient billing for COVID-19 testing, treatment By Alia Paavola C ommonSpirit Health, a Chicago-based system with 142 hospi- tals in 21 states, will suspend patient billing related to the test- ing and treatment of COVID-19. "The last thing our patients should worry about if they experience symptoms characteristic of this coronavirus is the cost of seeking care," said Lloyd Dean, CEO of CommonSpirit Health. With its March 17 announcement, CommonSpirit Health joins a grow- ing list of health systems halting bills for patients being tested and treated for COVID-19. A week prior, Advocate Aurora Health, a 28-hospital system with headquarters in Milwaukee and Downers Grove, Ill., and Providence, a 51-hospital system in Renton, Wash., announced they would hold off sending patients bills for the testing and treatment of COVID-19. Halting medical bills for patients seeking care related to COVID-19 is not an industry-wide standard. n

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