Aetna settlement information

Web site links will take you off the AMA Web site. The AMA is not responsible for content of other Web sites.

Alert: The Aetna settlement expired June 2, 2008. Read Aetna's press release regarding the expiration and its Guiding Principles for Physician Relations. 

The following documents will help you understand your rights under the Aetna settlement agreement. (PDF files requires Adobe® Reader®.

How the Aetna Settlement Agreement helps the physician practice (PDF, 268KB) flyer contains a summary of the key business practices mandated in the Aetna settlement. Since contracts provided by Aetna to physicians in its provider network must conform to the settlement, physicians are encouraged to review their contracts to ensure they are receiving available protections.

Aetna Compliance Dispute Resolution and Retroactive Medical Payment Policies (PDF, 27KB)

Codes to be reprocessed when billed with an E/M Code appended with Modifier 25 (PDF, 15KB)

Important Message Regarding Aetna's Payment Policy for Urinalysis Dipstick and Pulse Oximetry When Billed with Evaluation and Management Codes (E/Ms) Appended with Modifier 25. (PDF, 22KB)

Important Message Regarding Aetna’s Payment Policy for Modifier -57 for Evaluation and Management (E/M) Services at Which Decision for Surgery Is Made (PDF, 12KB)

Aetna reached an agreement with state medical societies and changed its payment policy to reimburse for EKG 12-Lead service procedures when billed with an emergency room E/M code as of Aug.12, 2006. The deadline for resubmission of previously denied claims for physicians (including participating, non-participating and retired) was Nov. 11, 2006.

Pertinent information:

Date settlement reached by parties: May 21, 2003

Final approval date: Oct. 24, 2003

Value of settlements: In excess of $470 million

Retrospective relief: $120 million

• $100 million to settlement fund
• $20 million to Foundation

Prospective relief: $300 million

Questions about the settlement may be directed to Whatley Drake & Kallas, L.L.C., at (866) 809-8003.

Compliance dispute facilitator (CDF)
Physicians may consider filing a "compliance dispute" if prohibited clauses are contained in a health plan’s contract or if the health plan fails to adhere to the terms of its settlement. After the dispute is deemed valid by the CDF, the CDF will act as the physician’s representative unless the physician or Signatory Medical Society, acting on the physician’s behalf, elects to employ separate counsel. Below is the contact information for the Aetna CDF:

Cameron C. Staples
Neubert Pepe & Monteith, PC
195 Church Street
Phone: (203) 821-2000
Fax: (203) 821-2009

Online information will be available in December 2006
Aetna will post key information, including detailed instructions and forms that are required to ensure timely and accurate processing of the resubmitted claims, on their Web site. Information and forms will also be posted on www.aetna.com in December 2006.

To learn more about foundations created by the settlements, please go to the Physicians Foundation Web site.

For Aetna dispute procedures, click on the links below:

Aetna Dispute Category List (PDF, 10KB)

Aetna Compliance Dispute Procedure (PDF, 70KB)

Aetna External Billing Dispute Procedure (PDF, 75KB)

Aetna Compliance Dispute Claim Form:

Aetna Compliance Dispute Claim Form (PDF, 16KB)