Health plan RICO settlement provides a way to fight downcoding

LETTER — Posted Jan. 3, 2005

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In response to your front-page article on physicians' tendency to downcode in anticipation of what insurance companies will reimburse -- "Do you tend to undercode? You're not alone" (Article, Nov. 22, 2004) -- now is the perfect time to reverse that practice.

The RICO (Racketeer Influenced Corrupt Organizations) Act physician class action suit against the managed care industry identified automatic downcoding as one of the industry's major "rackets." Aetna and CIGNA have settled with physicians. The settlements prohibit automatic downcoding, and the RICO attorneys are holding them to their word.

When a Virginia physician filed a 99244 (consultation) and was paid for a 99214 (office visit) he filed a dispute. Aetna subsequently paid for the consultation.

More than 70 disputes have been filed by physicians to date. Topics have included downcoding, contract language, de-paneling, and requests for refunds from physicians. Birmingham, Ala.-based attorney Julia S. Stewart heads the settlement compliance team, and each of these disputes is taken very seriously.

Janis G. Chester, MD, Dover, Del.

Editor's note: Dr. Chester has served on several advisory committees related to the RICO class-action lawsuit and is a past president of the Psychiatric Society of Delaware.

Note: This item originally appeared at http://www.ama-assn.org/amednews/2005/01/03/edlt0103.htm.

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