American College of Cardiology

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:
As part of the agreement CIGNA will pay physicians for as many as 12 years of reimbursement dating back to 1990.

• $30 million to class members who choose not to submit documentation (Category A)
• No ceiling on amount for physicians to documenting past CIGNA claims (Categories I and II)
• Minimum of $15 million towards the newly created Physician’s Foundation for Health Systems Improvement, Inc., controlled by the signatory Medical Societies

Filing for retrospective relief from CIGNA:
Either option must be exercised within 180 days of the beginning of the “Claims Period”, which has not yet begun. The settlement was deemed final on April 26, 2004 when a federal appeals court ruled the settlement was valid. Information regarding the start of the “Claims Period,” should be available shortly.

Option 1 — Accept a flat rate payment calculated on a pro rata basis based on the number physicians who select this option from a $30M Settlement Fund, without the necessity of submitting any documentation concerning claims (retired and deceased physicians receive twice as much as actively practicing physicians who will also benefit from the prospective relief), or

Option 2 — Prove claims were improperly downcoded, bundled or denied based on medical necessity, in one or more of the following three (3) ways: 1. Category One Compensation (Specified Coding or Bundling Edits) 2. Category Two Compensation (Other Coding or Bundling Edits) 3. Medical Necessity Compensation

Generally speaking, to pursue option 2 physicians must retain CIGNA Remittance Forms, copies of HCFA 1 500s submitted to CIGNA or internal accounting records (such as printouts of accounts receivable records or paid account records), and with respect to most requests for Category Two compensation and all requests for Medical Necessity compensation a complete copy of the relevant medical records, back to August 4, 1990.

Prospective Relief: as determined by an independent actuarial review

• In excess of $400 million, some valuation in excess of $1 billion

Enforcement
CIGNA 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 Cigna Settlement PDF.