| CIGNA
Settlement Update - Claims Period Begins August 23
In
April 2004, a federal appeals court upheld a $540 million
settlement of the lawsuit between 700,000 physicians and CIGNA.
As part of the settlement agreement, CIGNA recently announced
a claims period for physicians to submit requests for payment.
Eligible physicians will have from August 23, 2004
to February 18, 2005 to submit their claims. CIGNA
plans to notify all physicians by mail.
Background
The CIGNA settlement stems from class action lawsuits brought
by several medical societies against several national and
regional managed care companies. Physicians argued that the
health plans engaged in fraud and extortion in a common scheme
to wrongfully deny payment to physicians. The lawsuits are
scheduled to go to trial on September 13, 2004, but two of
the defendants, Aetna and CIGNA, reached settlement agreements
in 2003. As part of its settlement, CIGNA will pay physicians
as many as 12 years of reimbursement dating back to 1990.
More information about this settlement can be found at http://www.acc.org/pmr/resources/cigna_summ.htm.
Filing
for Retrospective Relief from CIGNA
Physicians who wish to submit a claim with CIGNA for retrospective
relief have several filing options. All forms and instructions
for filing are available at www.hmosettlements.com
and an explanation of this process is below.
Option 1 – Category A Settlement Fund
Physicians
can seek compensation from the Category A Settlement Fund
without submitting claims documentation. The Category A Settlement
Fund is a $30 million pool of money that will be paid out
on an aggregate basis. Physician payments will be calculated
at the closing of the Claims Period and will be dependent
upon the number of physicians who filed Category A claims.
All payments from the Category A Settlement Fund will be made
approximately two weeks after the Claims Period has ended.
To
request Category A compensation, physicians must submit a
Category
A Proof of Claim Form by mail to the Settlement Administrator
at the following address:
CIGNA Physician Settlement
Settlement Administrator
P.O. Box 3170
Portland, OR 97208-3170
Option
2 – Claim Distribution Fund
The
Claim Distribution Fund is an uncapped settlement fund that
requires physicians to submit proof that prior claims were improperly
downcoded, bundled or denied based on medical necessity. The
Claim Distribution Fund is divided into three categories:
Category
One Compensation
Physicians who were denied payment or received reduced payments
because of specific claim coding and bundling edits are eligible
for Category One Compensation. For a list of code categories
that qualify for Category One Compensation, click
here. Codes listed without an asterisk
require documentation showing that codes were submitted for
reimbursement. Codes listed with an asterisk
require documentation showing that the codes were submitted
and that payment was denied or reduced. Acceptable
documentation includes copies of HCFA 1500 forms, CMS 1500
forms, CIGNA Remittance forms, or internal accounting records.
Physicians
who elect to submit claims for Category One Compensation must
complete a Category
One Compensation Proof of Claim form. Each request for
payment must relate to a single episode of care, although
it may seek compensation for multiple CPT codes. A separate
cover sheet is attached to the Proof of Claim form and must
precede each individual request for payment.
Category
Two Compensation
Physicians
who were denied payment or received reduced payments because
of claim coding and bundling edits (other than those specified
in Category One) are eligible for Category Two Compensation.
CIGNA has compiled a list of claims that are eligible for
Category Two Compensation, referred to as a Facilitation List.
Physicians may obtain a Facilitation List specifically related
to their claims by contacting the Settlement
Administrator by e-mail or by calling 1-877-683-9363.
Physicians
who elect to submit claims for Category Two Compensation must
complete a Category
Two Compensation Proof of Claim form. Each request for
payment must relate to a single episode of care, although
it may seek compensation for multiple CPT codes. A separate
cover sheet is attached to the Proof of Claim form and must
precede each individual request for payment. Supporting documentation
is required, including a complete copy of the patient’s
medical record. Acceptable documentation includes copies of
HCFA 1500 forms, CMS 1500 forms, CIGNA Remittance forms, or
internal accounting records.
Medical
Necessity Denial Compensation
Physicians
who believe that their claims were improperly denied as not
medically necessary are eligible for Medical Necessity Denial
Compensation.
Physicians
who elect to submit claims for Medical Necessity Denial Compensation
must fill out a Medical
Necessity Denial Proof of Claim form. Each request for
payment must relate to a single episode of care, although
it may seek compensation for multiple CPT codes. A separate
cover sheet is attached to the Proof of Claim form and must
precede each individual request for payment. Supporting documentation
is required, including a complete copy of required
clinical information. Acceptable documentation includes
copies of HCFA 1500 forms, CMS 1500 forms, CIGNA Remittance
forms, or internal accounting records.
Please
note: Physicians may seek compensation from either fund but
not both.
All claims forms and appropriate documentation can be mailed
to the Settlement Administrator at the following address:
CIGNA Physician Settlement
Settlement Administrator
P.O. Box 3170
Portland, OR 97208-3170
Physicians
who are denied their request for payment will be notified
by mail. Physicians will have 30 days to correct any deficiencies
in the request for payment and resubmit the claim. Once approved,
all payments from the Claim Distribution Fund will be made
within approximately 30 days.
ACC
is currently working with a claim auditing organization to
provide assistance to members who are interested in pursuing
retroactive reimbursement. More information will be made available
once the claim period begins.
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