Explanation of Benefits Was a$14.18 administrative fee intentionally disguised as a medicalprocedure on a patient's Explanation of Benefits? (Photo:Shutterstock)

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Administrative costs have been a common targetin the mission to identify the drivers of America's high healthcare spending. And the American Medical Association is sounding the alarm on health insurers who itsays are trying to hide these costs through manipulation of itsmedical coding system, the Current Professional Terminology.

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Writing in a judicial advocacy post, the AMA is calling forVirginia's 4th District Court of Appeals to overturn a ruling thatcleared Aetna and Optum of misusing CPT codes to charge anadministrative fee when creating a patient's billing statement.

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Related: 30 percent of consumers don't understand what anEOB is

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At issue is a $14.18 charge appearing on an Explanation ofBenefits statement for Sandra Peters following a chiropracticvisit. According to the lawsuit, Optum was listed as the providerof the network and included the code to bill an administrative feeto insurer Aetna. The court ruled against Peters, in part because"Under the Aetna-Optum relationship, Optum receives payments onlyfrom Aetna itself, never from an Aetna member or plan sponsor."

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The codes are supposed to be used only for medical procedures,the AMA asserts, and not as a "catch-all" for elective charges to ahealth plan. In its brief, the AMA alleges that "the defendantssearched for a CPT code that would be difficult for laymen tounderstand in order to 'bury' (their word) their administrativefees so that they could assert an unjustified, uncontracted charge… They assumed no one would understand and, because the chargelooked official, no one would challenge it."

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In addition, the AMA says the ruling was erroneous intreating Optum as an employer and concluding that Sanders was notultimately responsible for the charge, stating that "they[Optum] are not providers like a physician or hospital, and thatAetna member Peters was asked to pay $14.18 for the charge."

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Though this is just once lawsuit, the AMA stresses that it is apart of a larger issue and shows "evidence of systemicmisrepresentations on the part of two health company giants, whichadminister benefits for millions of Americans."

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Moreover, as cost-conscious employers and consumers increasinglyare taking a closer look at the bills for the services they ortheir health plans are being billed for, the case shouldserve to further empower them to raise concernsabout questionable codes.

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Emily Payne

Emily Payne is director, content analytics for ALM's Business & Finance Markets and former managing editor for BenefitsPRO. A Wisconsin native, she has spent the past decade writing and editing for various athletic and fitness publications. She holds an English degree and Business certificate from the University of Wisconsin.