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AEtna Refunds citing ERISA

  1. #1
    Default AEtna Refunds citing ERISA
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    My doc is receiving a number of Aetna refund requests from 2009. It appears Aetna is auditing their self- funded plans and citing ERISA for their money owed. Is anyone else out there being bombarded with multiple refund requests? How are you managing them?

  2. #2
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    Quote Originally Posted by camilleb View Post
    My doc is receiving a number of Aetna refund requests from 2009. It appears Aetna is auditing their self- funded plans and citing ERISA for their money owed. Is anyone else out there being bombarded with multiple refund requests? How are you managing them?
    Could you be more specific? Or is that all the EOB says? Ask for full written disclosure...

    This is interesting, but I'm not sure it's relevant:
    http://www.aetna.com/producer/e.brie..._06_erisa.html

    And this:
    http://www.healthplanlaw.com/?p=1837

  3. #3
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    A non certified staff member coded his claims for open inguinal hernia repairs as: 49505 and 49568-59. When I came on last year, I read that he cannot bill for the mesh (49568) with open repairs. All year long in 2009, he was billing them this way. The overpymts are justified, but we are noticing that requests are coming via mail EVERY week. The Aetna plan are self-funded by the employer and are therefore protected by the ERISA act to recoup their money, regardless of state law.
    I am wondering if anyone else is experiencing this- and how are you planning to manage the refund requests? Setup payout arrangements?

  4. #4
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    Ooohhhh...okay, well, you definitely have to refund the money (ERISA or not); you have a legal responsibility to immediately refund overpayments caused by incorrect coding, once the problem is identified. The problem, here, is that it's never a good idea to send an unsolicited refund to Aetna (as I have been warned against doing, by Aetna)...If the refund doesn't accompany an Accent overpayment account, it just sends them into a tizzy, and they have absolutely no idea what to do with it. We even had them hold up one of our paid EOB's for 6 months in "reprocessing," because there was a refund mix-up caused by an unsolicited refund on one account.

    The moral of the story is, if you have to send a refund to Aetna, you should contact them and find out if they can send you a refund request if you identify an overpayment; don't just send it in.

    Also, don't wait to contact them about an overpayment, hoping they won't notice and will leave you alone. It's not your doctor's money; they don't get to keep it. Holding on to it when you know you've got an error is playing Russian Roulette with the OIG.

    Since you're already getting in refund requests, I would advise you to put together a spreadsheet of all of the overpayments you've identified (run a report if you have to), with every account, DOS, and payment amount that has to be returned. Then contact an Accent representative (Or whatever 3rd party company is handling your refund requests) and tell them that you need assistance in returning overpayments to Aetna. You need to compare which accounts they have sent refund requests on, to the accounts that you have, so that you can see what all has been refunded, and can send the outstanding overpayments in a way that they will be correctly accounted for and applied. It's going to be a lot of work, but it's the least you can do to remain compliant.
    Last edited by btadlock1; 04-01-2011 at 09:33 AM.

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