A sign at Aetna's headquarters offices in Hartford, Connecticut. Credit: JHVEPhoto/Adobe Stock
Aetna is about to expand an existing health claim cost control effort Sept. 1.
The CVS Health subsidiary is adding more types of claims to a Claim and Code Review Program that subjects certain types of claims to a more intense level of review.
Aetna has already been using the program to review emergency room services and some other services.
Starting next week, the insurer intends to use the program to review "high-dollar claims, implant claims, anesthesia claims and bundled services claims, to help confirm coding accuracy," according to a notice the company posted in June.
The program will affect claims sent to commercial health plans, including fully insured group health plans. It will also affect Medicare plans and student health plans.
U.S. health care providers use diagnosis codes based on the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification, standard, which is commonly known as the ICD-9-CM standard.
U.S. providers use procedure codes based on the American Medical Association Current Procedural Terminology, or CPT, standard.
Health insurers and benefit plan administrators see claim editing as a strategy for coping with accidental provider diagnostic and procedure coding errors and for defending themselves against provider strategies for overbilling.
Insurers and administrators say some providers overbill through strategies such as "upcoding," or using excessively high-intensity, high-cost claim codes for procedures, and by "unbundling," or billing separately for items and services that have traditionally been bundled into the same procedure code.
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Providers have objected to health insurers' and plan administrators' claim editing strategies and accused payers of intentionally "downcoding."
The California Medical Association, the Indiana State Medical Association and the American Podiatric Medical Association are examples of provider groups that have questioned Aetna's approach to claim editing.
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