Aetna, Optum misused CPT codes to hide administrative charges, AMA says

The American Medical Association said Aetna and Optum misused Current Professional Terminology codes to hide administrative costs, according to a judicial advocacy post

The post concerned an amicus brief the AMA filed in the case Peters v. Aetna. In the brief, the AMA said the 4th District Court of Appeals in Virginia should overturn a previous judgment that denied the companies' liability in passing administrative charges through CPT codes.

According to the AMA, an explanation of benefits to plaintiff Sandra Peters and emails between the companies' employees showed Aetna used code 97039 to charge Ms. Peters an administrative fee when billing for a chiropractic visit. 

According to the AMA, a lower court decision ruled: "Optum is the provider of the network, the [explanation of benefits] identifies Optum as the 'provider' for the service and reports a total 'amount billed' which includes the flat-rate contractual fee to Optum and the CPT code required by the Aetna-Optum contracts. … Under the Aetna-Optum relationship, Optum receives payments only from Aetna itself, never from an Aetna member or plan sponsor."

In calling on the court to overturn the decision, the AMA said the defendants didn't legitimately choose a CPT code, they aren't a provider like a physician or hospital, and as an Aetna member, Ms. Peters was asked to pay the administrative charge.

Read more here.

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