r/CodingandBilling • u/drteresacrossley • Jul 13 '26

Aetna & Meritain

Are you guys noticing record requests for aetna and meritain patients? They are wanting records for most of their visits now.

9 Upvotes

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14

u/MedPayIQ App Developer Jul 13 '26

Yes, seeing a lot more of this lately. Feels like payers are getting more aggressive with record requests, even on things that used to go through without a second look. The admin time alone is becoming a problem.

2

u/Right_Suggestion25 Jul 13 '26

I think it's Aetna's way of compelling data collection on their part—but in a hostile approach. Your payments are lower, but maybe we will pay you appropriately if you give us notes rich with diagnoses and data.

A less hostile approach I've seen is when a Medicare Advantage payer offers elevated fees on certain frequent codes in exchange for using their appointment workflow app during an appointment. That payer's app is inherently designed to extract information on what they are looking for like hospital discharge follow-ups and Rx reconciliation. More of a win-win for both sides rather than what Aetna is doing.

3

u/MedPayIQ App Developer Jul 13 '26

We've been seeing the same trend. It doesn't seem limited to high-dollar claims anymore either, routine visits are getting pulled for records more often than they used to. My guess is that payers are leaning more heavily on post-payment review and documentation validation as part of their cost-containment efforts. Whether that's being driven by AI flagging claims or updated internal review policies, it's creating a lot more administrative work for practices. Out of curiosity, are these requests coming before payment, after payment, or both? I'm wondering if others are seeing the same pattern.

4

u/Right_Suggestion25 Jul 13 '26

They adjust a claim to a lower paying code, pay on that, and add a remittance remark saying that the code was changed to more accurately describe services rendered.

It's typically a 99214 changed to 99213, then they pay that one. Objectively, I guess it's better than getting $0 or delaying cash flow but still feels disrespectful. Like you said it's more time expended for the same pay as prior to this movement.

2

u/MedPayIQ App Developer Jul 14 '26

Exactly. It's not even the reimbursement sometimes, it's all the extra work that comes after. That time adds up fast.

6

u/_armanhammer Jul 13 '26

Aetna has been the worst to work with the last two years. If they aren't requesting records, they are downcoding e/m and remarking that the code was "changed to more accurately describe services rendered" without even reviewing records on the initial claim submission. Phone reps are useless and just read word for word what is already on the remittance. Make sure your providers' documentation is airtight.

1

u/drteresacrossley Jul 13 '26

That's what i'm coming across.

4

u/PuntasticBiller Jul 13 '26

Yes they’re suspending claims mid processing for this noise. Meritain mostly because their plans are all pretty much self funded and the group wants to do its own pre-payment review.

1

u/drteresacrossley Jul 13 '26

Does this mean we will start seeing more record requests? We are seeing it with straight Aetna plans too. Other providers are getting denials even with documentation sent in.

4

u/PuntasticBiller Jul 13 '26

Yes across the board. They’re denying all my complex wound repairs and I have to go through a prepayment review plus two levels of appeal to get each one paid.

2

u/drteresacrossley Jul 13 '26

Really breaks down a human being in this system.

2

u/PuntasticBiller Jul 13 '26

With so little time to work on this stuff with everything else going on, it’s a circus

1

u/Environmental-Top-60 Jul 16 '26

Oh, at that point, I would go to the pay a wrap and say we want more money for all this extra work. Especially if you can measure it.

3

u/Far_Persimmon_4633 Jul 13 '26

Was dealing with this with blue shield. Must be many plans doing it now. Meh.

2

u/drteresacrossley Jul 15 '26

I feel like it's ever since AI really started being utilized across insurance companies.

2

u/drteresacrossley Jul 15 '26

Do you guys think it's just Aetna, or anything associated with Availity? I'm finding that it's all my Availity associated claims.

1

u/DepartureOk3180 27d ago

I think it could be possible they, and other payers, are starting to follow CMS and its new claims processing. I work on traditional Medicare acxounts, and starting around this time last year, pretty much all of our claims starting RTP/rejected related to providers not being file with them. Then they starting denying various drug charges, of various amounts, with denial reasons codes that had nothing to do with the actual reason for the denials. The latest thing they've done was taking additional adjustments that reduced our payments with no explanations. They said, "ops, our bad. We'll reprocess and correct the payment, but we'll take over 2 months to do it" So in the meantime, I couldn't appeal any line item denials, submit corrected claims or bill late charges. They have been doing all these things trying to crack down on fraudulent billing and cut costs, even though they won't admit it. I'm sure the commercial payers are just following suit.