Aetna implements non-standard severity adjustment policy, creating coding misalignment risk for hospitals

Aetna has deployed a proprietary patient severity scoring methodology that deviates from the standard CMS-HCC risk adjustment model used by Medicare and most other payers. This non-standard policy creates significant reimbursement risk for providers, as claims coded under traditional models may not align with Aetna’s internal calculations, potentially leading to underpayments. Hospitals and health systems with substantial Aetna commercial contracts must audit their current severity documentation and coding processes against Aetna’s new guidelines immediately to identify and mitigate revenue gaps.