Class-action lawsuits against insurers: Settling for fair treatment

The power of organized medicine and the attention of individual physicians will ensure that settlements with managed care companies result in better conduct toward doctors.

Posted April 5, 2004.

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One of the lead private attorneys handling physician class-action lawsuits against managed care companies calls settlements with Aetna and CIGNA "one of the greatest victories the medical societies have achieved for their patients and their physicians," and it's easy to see why.

The settlements put the companies' feet to the fire, setting medical necessity standards, forcing them to follow CPT guidelines and otherwise creating more open communication between the companies and physicians. The AMA, state, county and specialty societies worked on physicians' behalf, providing considerable leverage to get, so far, Aetna Inc. and CIGNA Corp. to promise to act fairly.

As any physician knows, leverage is key in negotiating a managed care contract, and until these settlements, the leverage seemingly always belonged to the health plan. As co-lead counsel Archie Lamb Jr. said, "The voice of those medical associations corroborated what individual physicians said for years, and it was a bullet hole between the eyes to those plans mocking and humiliating individual physicians who chose to step forward."

Organized medicine is involved in similar lawsuits and settlement discussions against companies such as Anthem Inc. and WellPoint Health Networks Inc., which recently finalized their merger to become the nation's largest plan. This provides the possibility that even more plans will see the light and decide to treat physicians with some measure of respect, ending the unfair business practices by managed care companies that have tainted their relationships with doctors.

The Aetna and CIGNA settlements are being wrapped up as the U.S. District Court in Miami, which is overseeing them, hears the last appeals on those cases. But organized medicine is urging physicians not to wait in making sure that they get the maximum out of these settlements.

To that end, they recommend physicians look at a Web site (link) created by the plaintiff's attorneys in the Aetna and CIGNA cases. The site gives physicians the details on every settlement. It includes what individual physicians must do to get a share of money for past offenses such as downcoding -- for example, in the CIGNA settlement, physicians can resubmit claims for which they believe to be underpaid. Physicians could be leaving tens of thousands of dollars on the table if they don't resubmit.

Also, the Web site spells out how any future disputes will be handled against the companies that have settled. Each settlement has its own process in how a physician would dispute a claim, or would complain about company conduct.

The Web site should be a handy reference to physicians to ensure that they get what's coming to them, although it won't be the only resource available. The AMA and other societies also stand ready to answer questions from physicians about the settlements and how they will affect individual doctors.

This is not to say that physicians would notice an immediate turnaround in their fortunes once the settlements are fully implemented. What is true is that organized medicine has given physicians leverage they didn't have. With the pressure from organized medicine, and the vigilance of individual physicians, the medical community can see to it that health plans no longer run roughshod over physicians with impunity again.

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