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Aetna Audit Law Defense Services


Aetna Audit Law Defense Services

Aetna, like every other major commercial insurance carrier, routinely audits healthcare providers to ensure that billing is done correctly and in compliance with its policies and guidelines. Aetna can be particularly aggressive in pursuing recoupments of previously paid claims. Goldberg Law Group has years of experience helping providers navigate audits: here’s our guide for what to expect during an Aetna audit – and how we can help.


Aetna Auditing Healthcare Practice for Billing Compliance


As any healthcare provider knows, post payment audits by insurance carriers are a fact of life and to be expected. Insurance companies will seek to identify and recover any overpayments they might have made. 


Audits therefore pose a serious financial threat to any healthcare provider, and for those who rely especially on Aetna payments in their practice, an audit by Aetna can be damaging without proper support and defense. 


Goldberg Law Group’s Experience in Audit Defense


The Illinois third party payer audit defense attorneys at Goldberg Law Group deliver insurance audit services to doctors, chiropractors, behavioral health providers, clinical laboratories, and other healthcare providers and suppliers. We routinely advise and assist clients through the process of pre and post payment reviews conducted by Aetna. Through years of experience, we have developed a unique approach that is designed to help clients navigate third party payer audits in an efficient and cost-effective manner, incorporating the expertise of medical coding and documentation consultants where necessary.


Common issues that lead to an overpayment


Oftentimes Aetna’s post-payment audit process seeks to uncover incidence of overpayment. 


Here are some of the most common reasons an overpayment might be identified:


Incorrect coding - Proper medical coding for all services is crucial. Services or procedures that are incorrectly coded will generally result in an overpayment.


Improper documentation - For a number of reasons - not just billing - proper documentation is vital to any service provider. It should not only substantiate that services were provided but also that the services billed to the third party payer are correct.


Lack of coverage by the payer’s medical policy - It is important to carefully read every third party payer’s medical policy to ensure that all services billed for are covered by the payer’s medical policy and that all conditions for coverage are satisfied. 


Lack of coverage in patient’s benefits policy - Occasionally, services can be billed to the payer that are not, in fact, covered in the patient’s benefits policy. 


Service is not medically necessary - Payers may determine certain services are not medically necessary and therefore ask for return of payment. Oftentimes these are determined from a risk management perspective. 


Typically overpayments occur when services are incorrectly coded, not properly documented, not covered by the payer’s medical policy, not covered by the terms of the patient’s benefits policy, or are determined by the payer to not be medically necessary. 


How to Be Prepared for an Aetna Audit


There are several steps you should take in response to an Aetna audit. First and foremost, determine the purpose and scope of the Aetna audit. The purpose and scope of the audit can often be determined from the letter or email Aetna issues notifying the healthcare provider of the audit. You should also carefully review the names of the patients and dates of service requested to ensure that the requested information is within your possession.


At this point, it’s time to gather patient records and review their contents. Check to make sure all aspects of the record including treatment plans, procedures, diagnostics, and medication prescriptions are complete. In addition, check to make sure all third party records related to your care or treatment of the patient (e.g. laboratory and diagnostic reports) are incorporated into the patient’s chart. Finally, review the records in conjunction with the claims that were submitted for payment to ensure that the codes used to bill for services are compliant with documentation and coding standards. 


Frequently Asked Questions


Why is Aetna auditing your healthcare practice?


Aetna routinely audits all healthcare practitioners to ensure an overpayment has not occurred. It will also choose to audit practices with suspicious billing patterns that might indicate fraud or lack of compliance with gudelines.


What are your rights during an audit?


During an Aetna audit or any other provider audit, you first and foremost have the right to engage legal counsel to defend against the audit. You also have a right to defend your billing practices as well as a right to defend against liability and charges.


What are the risks of an audit?


The major risk of an audit is financial, in that payments can be reversed if Aetna deems they paid in error and should be refunded. Aetna can also require pre-payment review of future claims, require corrective action plans to monitor billing compliance, and even involve state and federal authorities depending on the circumstance. 


Can you contest an unfavorable outcome to an Aetna audit?


You can contest Aetna’s overpayment determination by filing an appeal, which may reduce your financial liability. As one might expect, defending a payer audit  can be time consuming, so it is best to mount a strong defense at the outset upon receipt of notice of an audit.



Goldberg Law Group brings years of expertise to every audit defense case with its team of healthcare lawyers who routinely defend against Aetna audits in Illinois and Arizona.


About to undergo an Aetna audit? Get in touch today to prepare with professional help.


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