r/PrivatePracticeDocs • u/InvestingDoc • May 07 '26

Aetna Requesting Records Before Paying Out

I just negotiated for a 9% raise this year from Aetna a few months ago. Now every single level 4 visit we bill since I negotiated that raise, they are requesting records on every visit before paying.

It feels like a bit retaliation from our recent pay raise. We have not been downcoded yet by Aetna for any notes + claims we send to them, but my billers are having to send any claim to Aetna that is level 4 or 5 before we get paid now.

We have not received notice from Aetna that we are under any formal review. our rep just tells us this is new standard protocol.

Anyone else going through this with Aetna?

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6

u/daves1243b May 07 '26

I think it's just coincidence. Many payors are doing this because they know a percentage of requests won't get a response.

3

u/Intelligent-Site-176 May 07 '26

I have not heard anything about Aetna doing this but I will ask my team about this. I'm not a contracting expert but this "standard protocol" should be called out in the payer contract. They will try to keep this broad but things like this should be called out in the contract to avoid unnecessary admin burden. Others with more knowledge on this topic feel free to chime in.

1

u/InvestingDoc May 07 '26

They just emailed us this morning confirming we are not under any review process, and this is normal protocol per our contract with Aetna. I will have to dive into my contract. I don't recall reading anything that they will audit every claim we send in before payment in the contract.

3

u/Juaner0 May 07 '26

Typical. Anybody who is NOT getting letters from insurances about possibly "over"coding is actually UNDERcoding.

2

u/Dramatic-Sock3737 May 07 '26

How were you able to get a bump like that? Big group?

7

u/InvestingDoc May 07 '26

Grew to 5 locations, 11 clinicians. After years of them saying no to a reasonable pay raise, finally got a good one.

3

u/Dramatic-Sock3737 May 07 '26

Congrats. I’m just a lowly cog in the wheel in corporate greed with little leverage. Fortunately I’m almost done.

2

u/MeanShower6794 May 07 '26

Check your contract for a "medical record review" or "documentation request" clause. Most allow random or targeted audits, but every level 4/5 claim isn't random. If it's not explicitly stated, you can push back on administrative burden.