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Aetna Audits

Find Out What You Need to Know if You Are Preparing for an Aetna Audit

Aetna audits healthcare providers that participate in Medicare Advantage plans for compliance with its billing rules and requirements set by the federal government. These audits can present substantial risks—up to and including the risk of exclusion in some cases. Even when Aetna audits don’t lead to exclusion, they can still lead to recoupments, payment denials, prepayment review, and other penalties. As a result, a proactive approach is critical, and targeted providers need to ensure that they are prepared to defend their billings effectively.

We have extensive experience advising healthcare providers during Aetna audits. If you have received an audit notice from Aetna, our former federal agents can help ensure that you are fully prepared for what comes next. We can help you get ready for the audit, communicate with Aetna’s auditors on your behalf throughout the process, address any issues that arise, and do everything possible to protect you from an unjustified adverse outcome.

Why To Choose Fortis for Your Aetna Audit

At Fortis, we advise healthcare providers during Aetna audits nationwide. We have helped all types of providers protect their ability to bill Aetna while avoiding recoupments and other unnecessary penalties. Why should you choose us for your Aetna audit? Here’s what we have to offer:

  • A Team of Former Federal Agents – Our team is comprised of former federal agents who have devoted their careers to handling matters involving healthcare billing compliance and healthcare fraud. As a result, we understand Aetna billing compliance procedures inside and out, and we are intimately familiar with the types of issues that can expose providers to potential liability.
  • Significant Experience Handling Aetna Audits – Having advised numerous providers during their Aetna audits, we have a comprehensive understanding of Aetna’s audit methodology and procedures, including their risk adjustment program and the circumstances under which CMS makes monthly payments to different MA organizations. We also understand Aetna’s enforcement priorities, and we know what types of issues tend to create the most trouble for audited providers.
  • Experience on Both Sides of Healthcare Audits – As former federal agents, our consultants have experience on both sides of healthcare audits involving both private and public payors. This breadth of experience gives us unparalleled insight and allows us to provide strategic and proactive advice to our clients.
  • Nationwide OnSite and Remote Capabilities – Our audit consulting practice is nationwide in scope. While we are able to provide many of our services remotely, our former federal agents can also be on site on a moment’s notice when necessary. In all cases, we take a highly strategic approach focused on providing the highest possible level of service as cost-effectively as possible.
  • CustomTailored Advice and Consultation – We take a custom-tailored approach to providing advice and consultation during Aetna audits. Every Aetna audit presents unique challenges and risks; and, as a result, a unique approach is required. When you engage Fortis to assist with your Aetna audit, we will develop and execute a strategy focused on protecting your practice with maximum effect.

Put our highly experienced team on your side

Dr. Stephen Taylor

DOL Consultant

Roger Bach

Former Special Agent (OIG)

Chris Quick

Former Special Agent

Kevin Smith

Former Assistant Regional Inspector General

Michael Koslow

Former Supervisory Special Agent (DOD-OIG)

James Hunt

Former Special Agent-in-Charge (DEA)

Common Issues During Aetna Audits

Aetna’s auditors spend their days examining participating providers’ billing records. Their job is to uncover billing violations, and they use a variety of tools, tactics, and tricks to do so using their medical record review process. Unfortunately, while some of their allegations of fraudulent billing are warranted, Aetna audits frequently lead to unjustified outcomes. Engaging our firm to manage the audit process on your behalf can help ensure that this doesn’t happen.

When examining participating providers’ billing records, Aetna’s auditors look for numerous types of billing miscues and anomalies. The following is a non-exclusive list of potential issues that can lead to recoupment demands, payment denials, prepayment review, exclusion, and other penalties:

  • Billing and coding errors, improper high risk diagnosis codes
  • Billing for non-covered medical services, supplies, or tests
  • Billing for medical services, supplies, or tests that are not medically necessary
  • Double-billing Aetna and other payors
  • Failure to follow appropriate intake procedures
  • Failure to follow appropriate discharge and referral procedures
  • Failing to maintain adequate documentation to substantiate Aetna billings
  • Improper billing practices (i.e., upcoding and unbundling)
  • Inadequate staff training
  • Missing dates and signatures

Along with these types of general issues, Aetna’s auditors look for compliance with the company’s service-specific billing rules and restrictions as well. For example, providers can (and often do) face recoupments and other penalties during Aetna audits due to billing violations such as:

  • Failing to maintain age-appropriate immunization records
  • Failing to properly provide and bill for family planning services
  • Improperly billing for substance abuse treatment services

Again, these are just examples. Aetna audits tend to be extremely comprehensive, and any perceived billing violations can put providers at risk. As a result, providers must take a comprehensive approach to protecting themselves during Aetna audits as well. At Fortis, we know what it takes to manage an Aetna audit successfully, and our former federal agents can use their experience, knowledge, and insights to help protect you and your business or practice.

How We Can Help During Your Aetna Audit

What exactly can we do to help? Here is what you can expect when you engage Fortis to assist with an Aetna audit:

1. Intervention in the Audit Process

Once you engage Fortis, our former federal agents will promptly intervene in the audit process. We will ensure that Aetna’s auditors are following all requisite procedures and are not overreaching. Both of these are significant concerns that can greatly expand the risks of facing an Aetna audit.

2. Assessment of Your Audit Risk

Once we have stabilized the situation, we will conduct an assessment of your audit risk. To do this, we will examine your business’s or practice’s relevant billing records and compliance documentation. Knowing what (if anything) Aetna’s auditors are going to find is essential for developing an effective audit defense strategy.

3. Audit Defense Strategy Development and Execution

Our next step will be to develop an audit defense strategy that is custom-tailored to the circumstances at hand. We will then execute this strategy to help ensure that the consequences of the audit are no greater than necessary.

4. Direct Engagement with Aetna

When executing our defense strategy, we will engage directly with Aetna on your behalf. This direct engagement proves essential in many cases. By engaging with Aetna directly, we can help address any issues before they turn into bigger problems. This can both reduce the costs you incur as a result of the audit and help to minimize any adverse outcomes.

5. Targeting a Favorable Resolution

Throughout the audit process, our efforts will be focused on targeting a favorable resolution in light of the specific circumstances at hand. If we can demonstrate full compliance on your behalf, we will. If we need to work with Aetna to address any past billing violations on your behalf, we will use our experience to help protect your ability to bill Aetna and ensure that any financial liability is reduced to the fullest extent possible.

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FAQs: How To Handle an Aetna Healthcare Billing Audit

Why is Aetna Auditing My Healthcare Business or Practice?

Aetna regularly audits participating providers to assess their billing compliance. But, in addition to conducting audits as a matter of course, Aetna also conducts targeted audits when its billing data or information received from other sources indicate potential non-compliance. Understanding why you are facing an Aetna audit is a key first step toward executing an effective audit defense strategy.

What Are the Potential Outcomes of an Aetna Healthcare Billing Audit?

The potential outcomes of an Aetna healthcare billing audit range from a finding of compliance to exclusion from billing Aetna in the future. In between, providers can face recoupments (or “reversals”), denial of pending claims, prepayment review, and other penalties designed to promote compliance going forward.

How Can I Protect My Business or Practice During an Aetna Audit?

Protecting your business or practice during an Aetna audit requires a proactive and strategic defense. At Fortis, we have extensive experience assisting clients with Aetna audits, and our former federal agents can work with Aetna on your behalf to help facilitate a favorable resolution.

What if I Disagree with the Outcome of an Aetna Audit?

If you disagree with the outcome of an Aetna audit, you can challenge the outcome through Aetna’s appeals process. In addition to assisting our clients with their Aetna audits, we assist participating businesses and practices with Aetna audit appeals as well.

Do I Need to Engage a Consulting Firm for an Aetna Audit?

Due to the challenges and risks involved with facing an Aetna audit, engaging a team of experienced professionals to manage the audit process is strongly recommended. At Fortis, we work with our clients (and their legal counsel as necessary) to help them avoid unnecessary financial penalties and protect their ability to bill Aetna.

Discuss Your Aetna Audit with a Healthcare Billing Compliance Consultant at Fortis

Are you preparing to go through an Aetna audit? If so, we encourage you to contact us promptly for more information. To speak with a senior healthcare billing compliance consultant at Fortis in confidence, please call 866-808-4160 or tell us how we can reach you online today.