Wiki Aetna denying problem visits as part of global ob

[tmerickson]

We are having a problem with Idaho Aetna denying OB problem office visits as part of the global ob care, when clearly they are not. ie: URI, Headaches, skin rash, etc. Even after going through their "reconsideration" request (first level of appeal), with supporting documentation including CPT definition of ob global care and proof that we can charge separate office visits for unrelated problems, they are still denying it. It's like they aren't even reading my letters! We only get 2 appeals with Aetna, and this is a huge amount of money we are loosing. Now, they have started going back through visits they have already paid on, and taking their money back. I've audited all of these visits and they truly are reimbursable services.

I am at my wits end. Does anyone have any suggestions? Does anyone have this problem as well? We don't have a provider relation rep assigned to us so I can't complain to them, but seriously, Aetna can't be withholding payments on billable services like this! HELP!

 

[CatchTheWind]

There is no easy way around this, but two of your options may be to try to get your doctor to speak to Aetna's medical director, or to file a complaint with your state's department of insurance.

We frequently struggle with this problem with Humana. For us, they are the ones who frequently don't even bother to read the letters before denying (and then upholding the denials).

 

[mitchellde]

Something to look at with this. If you are the provider also treating the pregnancy and you now have a visit outside of the global, try using a 24 modifier on the visit level, many payers will allow this as a way to indicate this is not part of the OB global. Be sure you are using the O code for the pregnancy first listed such as
O99.711
L30.8

 

[Tiffaney]

We are having a problem with Idaho Aetna denying OB problem office visits as part of the global ob care, when clearly they are not. ie: URI, Headaches, skin rash, etc. Even after going through their "reconsideration" request (first level of appeal), with supporting documentation including CPT definition of ob global care and proof that we can charge separate office visits for unrelated problems, they are still denying it. It's like they aren't even reading my letters! We only get 2 appeals with Aetna, and this is a huge amount of money we are loosing. Now, they have started going back through visits they have already paid on, and taking their money back. I've audited all of these visits and they truly are reimbursable services.

I am at my wits end. Does anyone have any suggestions? Does anyone have this problem as well? We don't have a provider relation rep assigned to us so I can't complain to them, but seriously, Aetna can't be withholding payments on billable services like this! HELP!

Did you find any solution? I am having the same problem, I bill w/ modifier 24 and they pay, then when the delivery charge goes thru they recoup everything, including a colpo stating "all is inclusive with Global Maternity". Any update would be appreciated.