Wiki Code R0070 in CMS fee schedule

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AmBaseer

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I work for a mobile xray and ultrasound provider and we use code R0070 to bill for transportation service. We are in the state of Illinois where Medicare follws the fee schedule set by NGS according to which R0070 is paid $116.23. We have been having an issue with Aetna as a Medicare Advantage payer that they pay only $3.99 for R0070 following the Medicaid fee schedule. The reason they give is that code R0070 is not found in the CMS fee schedule on CMS.gov. I checked with Medicare and they said it will not be on CMS.gov as it is determined by the local MAC, which in this case is NGS. Aetna will not follow the NGS fee schedule. What are our options in this case? Can we file a complaint with Medicare or is there a way to request that the code be updated on CMS.gov?
 
I'm not sure that Aetna has an obligation to follow the NGS fee schedule. I've looked briefly at the Medicare Advantage plan regulations but don't see this question addressed. The status assigned to R0070 by CMS is 'C' - 'carrier determined', and in this case, both Aetna and NGS are carriers, so it could be argued that each entity has been given the authority to determine their own rate for this code - MA plans certainly are given a lot of autonomy on how they operate and this may be a bit of a legal 'grey area'. I think this is a rather difficult question and maybe one that someone with a lot better knowledge of the regulations would need to answer.

Is your organization contracted with Aetna? If so, then I would recommend you escalate the issues with your network representative and/or try to negotiate a contract addendum or revision to rectify this. If you are not contracted, I don't think you have many options other than to decline to provide services to Aetna's patients. Aetna is a large and powerful bureaucracy and unless you are an organization with a lot of leverage and resources, it would likely cost more to try to litigate something like this than it would gain you in additional revenue.

Good luck and hope this helps some.
 
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thomas7331 said:
I'm not sure that Aetna has an obligation to follow the NGS fee schedule. I've looked briefly at the Medicare Advantage plan regulations but don't see this question addressed. The status assigned to R0070 by CMS is 'C' - 'carrier determined', and in this case, both Aetna and NGS are carriers, so it could be argued that each entity has been given the authority to determine their own rate for this code - MA plans certainly are given a lot of autonomy on how they operate and this may be a bit of a legal 'grey area'. I think this is a rather difficult question and maybe one that someone with a lot better knowledge of the regulations would need to answer.

Is your organization contracted with Aetna? If so, then I would recommend you escalate the issues with your network representative and/or try to negotiate a contract addendum or revision to rectify this. If you are not contracted, I don't think you have many options other than to decline to provide services to Aetna's patients. Aetna is a large and powerful bureaucracy and unless you are an organization with a lot of leverage and resources, it would likely cost more to try to litigate something like this than it would gain you in additional revenue.
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That is what we were thinking as well, that it might be best to stop taking the orders for Aetna patients. I wanted to ask here and see if we might have any other options before we make the final decision. Thank you for your input .
Could you direct me to the MA plan regulations and the site where it specifies the C status for the R0070 code? Those facts would be helpful to present the case for declining Aetna patients to our administrators .
 
AmBaseer said:
That is what we were thinking as well, that it might be best to stop taking the orders for Aetna patients. I wanted to ask here and see if we might have any other options before we make the final decision. Thank you for your input .
Could you direct me to the MA plan regulations and the site where it specifies the C status for the R0070 code? Those facts would be helpful to present the case for declining Aetna patients to our administrators .
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The status C assignment to R0070 can be found in the PFS relative value files, which you can access here:
(When you download the zip file, you can find a complete listing of all codes in the Excel document PPRRVU21 and an explanation of all of the indicators in the PDF document that is included in the zip file.)

The complete manual of Medicare Advantage regulations can be located here:
 
thomas7331 said:
The status C assignment to R0070 can be found in the PFS relative value files, which you can access here:
(When you download the zip file, you can find a complete listing of all codes in the Excel document PPRRVU21 and an explanation of all of the indicators in the PDF document that is included in the zip file.)

The complete manual of Medicare Advantage regulations can be located here:
Click to expand...
Thank you !
 
Hi AmBaseer, I have the same issue with EmblemHealth in NY. We are OON with them and they do pay when we file an appeal however they pay 58$ for the R0070 code. If I appeal a second time they do pay at the correct rate of 219.86$. I did file a complaint with CMS but I don't seem to be getting anywhere. I don't have any problems with Aetna. Curious, how did you make out? Have you tried filing an appeal with a copy of a redacted Medicare remit?
 
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