| In
2000, several medical societies brought class action lawsuits
against national or regional managed care companies, including
Aetna, Anthem, CIGNA, Coventry, HealthNet, Humana, PacifiCare,
Prudential, United Healthcare, and Wellpoint on the grounds
that the health plans engaged in fraud and extortion in a common
scheme to wrongfully deny payment to physicians.
The
class action lawsuits represent over 950,000 physicians who
have submitted claims to any of the above named managed care
companies. These cases were consolidated in U.S. District
Court in Florida and are known as the MultiDistrict Litigation
(MDL). A website devoted to the MDL and settlements is at
www.hmosettlements.com
Trial date is set for September 13, 2004. To date, Aetna and
CIGNA have reached settlement agreements, May 21, 2003 and
September 4, 2003, respectively in which both agreed to provide
relief in terms of payments to the plaintiffs and to change
their business practices.
The
components of each settlement represent: Retrospective Relief,
Prospective Relief, and Enforcement
Retrospective
Relief:
- $100
million to class members, without any requirement for the
submission of documentation
-
$20 million towards the newly created Physician’s
Foundation for Health Systems Improvement, Inc., controlled
by the signatory Medical Societies
Prospective
Relief: as determined by an independent actuarial
review
- In
excess of $300 million, some valuation in excess of $1 billion
Enforcement
Aetna agrees to make changes to their policies and
procedures related to coding, reimbursement and payment rules.
It is expected that the settlement will have it's greatest
impact on the change in carrier business practices or prospective
relief. By agreeing to:
- Allow
for greater transparency of it's claims processing,
- Evaluation
and Management Codes will not automatically downcoded
- Adhering
to most CPT coding edits (including payment for modifiers)
- Edits
must comply with key guidelines contained in the AMA
CPT Manual
- Payment
for vaccine administration, and
-
An independent review mechanism for billing and compliance
disputes
- If
a physician represented in the class action lawsuit
has an issue with Aetna or CIGNA on billing, medical
necessity or complying with the settlement that is not
resolved through the carrier’s appeal process,
the physician may then petition for a review by an outside
entity. Click
here to view the Step-by-Step Compliance Dispute Procedure.
Additional
settlement highlights:
- Disclosure
of Fee schedules
-
Disclosure of Payment Rules
-
Better Medical Necessity Definition
-
Capitation from Date of Enrollment
-
Optional participation in Pharmacy Risk Pools
-
Faster Credentialing
-
Protection of Non-Participating Physicians
Click
here to download the Aetna Settlement PDF |
