The California Medical Association (CMA) has received several reports from physicians in the San Francisco Bay Area that they’ve received contract termination notices from Aetna due to their above-average use of high-level Evaluation and Management (E/M) codes. The termination letters, issued by Aetna in mid-January, advised physicians that upon review of claims for a one year period, their usage of high level E/M codes was “significantly outside the norm” of comparative physicians within their market.
CMA has learned that approximately 40 physicians within the Northern California Aetna PPO network were issued the notice of termination. Contrary to the one-year timeframe for review stipulated in the termination notice, Aetna has advised that the review actually included approximately 30 months of prior claims data. Physicians whose billing pattern of high-level E/M codes exceeded two standard deviations above the mean for their assigned marketplace were issued a notice of termination per Aetna.
Patients’ access to care may be unnecessarily jeopardized if physicians are not offered a meaningful opportunity to appeal or address the underlying issue prior to physician termination from the network.
The inappropriateness of terminating physicians who billed outside the norm with respect to higher level E/M codes, without any prior-notice or opportunity to correct or explain the medical necessity of the care at issue, or to appeal the termination.
The termination of physicians based solely on their billing levels without first engaging them to discuss factors that may have led to higher than average billing, such as physicians treating a sicker patient base (e.g., HIV patients or seniors with underlying conditions), thereby wrongly punishing providers who treat these most vulnerable patients.
While physicians have been advised by Aetna of the right to request both a reconsideration of the Aetna E/M findings as well the ability to submit a separate appeal of their termination from the Aetna network, both processes failed to advise physicians of what information Aetna would consider relevant for review of this issue. However, feedback to CMA from physicians who were successful in the appeal of their termination highlighted valid reasons why their billing patterns differed from the norm, including being an urgent care practice or serving a high-risk population.
This underscores the need for physicians and their staff to carefully read all payor correspondence; ensure contractual notices of any kind are immediately routed to the physician for review and response; and call CMA with any questions.
Physicians impacted by the Aetna termination are encouraged to contact CMA at (916) 551-2865 or mlane@cmadocs.org for additional assistance.