Aetna Audits

Is Aetna auditing your healthcare practice for billing compliance? If so, it will be important to engage experienced defense counsel to help you avoid recoupment demands and other consequences.

Lynette Byrd
Attorney Lynette Byrd
Healthcare Fraud Team Lead
Former Federal Prosecutor
Nick Oberheiden
Attorney Nick Oberheiden
Healthcare Fraud Team
Kevin M. Sheridan
Kevin M. Sheridan
Healthcare Fraud Team
Former FBI Special Agent
Wade McFaul
Wade McFaul
Healthcare Fraud Team
Former HHS-OIG Assistant Special Agent-in-Charge

For healthcare providers that rely on Aetna health insurance reimbursements for a significant portion of their revenue, compliance with Aetna’s billing policies and procedures needs to be a top priority. Aetna, like other private health insurers, routinely audits healthcare providers for compliance, and in many cases it aggressively pursues “reversals” of previously-paid claims.

Regardless of your healthcare practice’s efforts to ensure Aetna billing compliance, if your practice is being audited, you need to engage experienced defense counsel. Aetna audits can be invasive, time-consuming, and confusing; and, in order to protect your practice, you need to know that you are relying on the advice of experienced attorneys.

During an Aetna audit, there is a lot that can go wrong. Auditors can make mistakes, your practice’s personnel can make mistakes, and what seemingly started as a “routine” inquiry can suddenly present the risk for substantial financial losses. Healthcare providers also need to be careful during Aetna audits to ensure that auditors do not exceed the scope of their authority and demand information or reverse claims that are not subject to review.

Experienced Healthcare Fraud Defense Counsel for Aetna Audits Nationwide

We represent healthcare providers in Aetna audits nationwide. Our firm’s lawyers and billing compliance consultants have remarkable experience handling all types of healthcare fraud matters. From Aetna audits to federal Medicare and Medicaid fraud investigations, we have successfully represented providers across the country in all types of inquiries, and we have helped the vast majority of our clients avoid reversals and other forms of liability entirely.

At Oberheiden P.C., we offer:

  • Highly Experienced in Healthcare Fraud Audits and Investigations – Our nationwide network of healthcare fraud defense lawyers and compliance consultants are highly experienced in healthcare fraud audits and investigations. In addition to experience as private defense counsel, this includes prior experience conducting and overseeing federal healthcare fraud audits and investigations at the U.S. Department of Justice (DOJ) and other agencies.
  • Lawyers and Compliance Consultants Who Know Aetna’s Rules Inside-Out – As a result of our extensive experience, we know Aetna’s billing rules inside-out. When you engage our firm for your practice’s Aetna audit, we will be able to hit the ground running and immediately provide knowledgeable, custom-tailored advice that is specific to your present circumstances.
  • Exclusive Representation by Senior Attorneys Experienced in Healthcare Fraud Audits and Investigations – Our firm is comprised entirely of senior attorneys and billing compliance consultants. We do not employ junior associates, paralegals, or administrative staff, so you can rest assured knowing that you are receiving experienced-based advice and counsel at every turn.
  • Proactive Advice and Representation for Aetna Audit Defense and Billing Compliance – We will take a proactive approach to your Aetna audit that is focused not only on mitigating the consequences of the audit itself, but also ensuring that your practice is well-situated to maintain (and demonstrate) compliance in the future.
  • Aroundthe-Clock Accessibility By Phone, Text, and Email – When your healthcare practice is being audited by Aetna, you do not have time to wait. We understand this, and we make ourselves available to our clients by phone, text, and email 24/7.

Common Billing and Recordkeeping Issues that Can Lead to Aetna Reversals

When faced with an Aetna audit, there are numerous potential issues that can lead to unfavorable consequences. Like all healthcare insurers, Aetna imposes and enforces a litany of strict rules and requirements, and even minor deviations can lead to problems for participating providers. For example, some of the types of issues that can result in reversals of previously-paid claims (in addition to other penalties) during an Aetna audit include:

  • Billing and coding errors such as upcoding, unbundling, and phantom billing
  • Billing for medically unnecessary or otherwise ineligible services, tests, medications, or medical supplies
  • Double-billing Aetna and patients, government healthcare benefit programs, or other private insurers
  • Failure to maintain adequate documentation to substantiate Aetna billings
  • Failure to maintain age-appropriate immunization records
  • Failure to appropriately schedule and bill for follow-up and return visits
  • Failure to properly provide and bill for family planning services
  • Failure to follow appropriate discharge and referral procedures
  • Improper billings related to alcohol and other substance abuse treatment services
  • Inadequate staff training (initial and/or on a periodic basis)
  • Maintaining illegible or incomplete patient records
  • Otherwise violating Aetna’s requirements for payment

This list is by no means exhaustive; and, during audits, Aetna meticulously scrutinizes providers’ records for any evidence of possible billing violations. If any such evidence exists, Aetna will take responsive action promptly—unless your practice is able to effectively intervene.

How to Defend Against an Aetna Audit

Given the multitude of issues that can lead to trouble for healthcare providers during Aetna audits, what can your practice do to avoid unnecessary consequences. As your practice’s defense counsel, during your Aetna audit we will:

1. Intervene

Our attorneys will promptly intervene in Aetna’s audit and examine the procedures the auditors are utilizing to ensure that they are not overreaching. We will deal with Aetna’s auditors on your behalf, and we will begin steering the audit toward a favorable result.

2. Assess

We will thoroughly assess your practice’s Aetna billing records in order to identify any compliance deficiencies and gather the documentation we need to present an effective defense. This step is essential to ensuring that our defense strategy is tailored to the circumstances at hand.

3. Strategize

Once we know what issues (if any) Aetna’s auditors are likely to uncover, we can then develop a targeted defense strategy. Our defense strategy will be designed to minimize your practice’s liability risk while also resolving the audit as quickly as possible.

4. Defend

With a strategy in place, we will defend your practice during its Aetna audit. We will challenge the auditors’ methods, assumptions, and conclusions, and we will work diligently to ensure that your practice is not unduly penalized.

5. Resolve

Finally, we will seek to resolve the audit with as favorable a result as possible. We will seek to minimize or eliminate any reversals, and we will seek to ensure that your practice is able to maintain a favorable billing relationship with Aetna going forward.

FAQs: What Do Healthcare Providers Need to Know about Aetna Audits?

Q: Why is Aetna auditing your healthcare practice?


Aetna regularly audits participating providers for compliance with its billing rules and requirements. The simple reason for this is that audits are a significant source of revenue for Aetna (and other private health insurers), as the allow for the opportunity to obtain “reversals” of previously-paid claims. If your practice is being audited, you will need to assert a proactive defense in order to avoid owing money to Aetna.

Q: What are the potential consequences of an Aetna audit?


The most-common consequence of an Aetna audit is liability for reversals. However, depending on the circumstances involved, Aetna may also: deny pending claims; require pre-payment review of future claims; require affirmative efforts to establish billing compliance; terminate eligibility; and, refer the provider to federal authorities for a civil or criminal healthcare fraud investigation.

Q: What are your rights during an Aetna audit?


During an Aetna audit, you have the right to defend your practice’s billing record and fight to avoid liability for reversals and other penalties. Importantly, you also have the right to engage legal counsel to defend against the audit on your practice’s behalf. When facing an Aetna audit, engaging experienced defense counsel is critical, as there are both substantive and procedural aspects to Aetna audits that require extensive knowledge beyond that held by most healthcare providers.

Q: How can you defend against an Aetna audit successfully?


There are various ways to successfully defend your healthcare practice during an Aetna audit. These include: (i) affirmatively demonstrating compliance with Aetna’s billing rules and requirements; (ii) pointing out flaws in the auditors’ methodologies and conclusions; and, (iii) when necessary, working with Aetna’s auditors to arrive at an outcome that allows your practice to correct any mistakes that have been made while still continuing to bill Aetna for services, tests, medications, and supplies.

Q: What if you disagree with the outcome of your practice’s Aetna audit?


If you disagree with the outcome of your practice’s Aetna audit, you can file an appeal. Aetna administers its own appeals process, and appeals will often be successful in reducing providers’ reversal liability—if not eliminating reversal liability in its entirety. However, while this is an option, it is best to avoid the need to file an appeal if at all possible. This is where executing a strategic defense during the audit process comes into play.

Read more about ZPIC/UPIC audits.

Put our highly experienced team on your side

Dr. Nick Oberheiden
Dr. Nick Oberheiden



Lynette S. Byrd
Lynette S. Byrd

Former Assistant U.S. Attorney


Ellen Comley
Ellen Comley

Senior Counsel


Roger Bach
Roger Bach

Former Special Agent (OIG)

Steven Taylor
Steven Taylor

Healthcare Compliance Consultant

Susan Sage
Susan Sage

Healthcare Auditor

Discuss Your Practice’s Aetna Audit with a Senior Healthcare Defense Lawyer at Oberheiden P.C.

Is Aetna auditing your healthcare practice? If so, our senior healthcare defense lawyers and billing compliance consultants can help. To learn more in a complimentary and confidential initial consultation, please call 888-680-1745 or inquire online now.

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