Physician feedback encouraged as health plan settlement shakes out

If you don't think CIGNA and Aetna are living up to their lawsuit settlement agreements, here's what you need to do to report problems.

By Tanya Albert Henry — Posted July 26, 2004

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Physicians, medical societies and lawyers who hammered out agreements with Aetna and CIGNA that will change the way the health plan giants handle physician claims have no reason to believe the changes won't go as promised.

But they aren't taking any chances.

The 40 medical societies that signed on to each agreement will help in making sure that the companies follow the settlement agreements and change their business practices.

"It's one of those trust-but-verify situations," said Connecticut State Medical Society Executive Director Timothy B. Norbeck. CSMS is one of the original medical societies to sue Aetna and CIGNA over the way they paid physicians. The Medical Assn. of Georgia, Texas Medical Assn., California Medical Assn. and more than a dozen other medical societies also were part of the original lawsuits.

But lawyers and organized medicine leaders said grassroots physicians also need to be alert for problems and report them so that the agreements are more than words on paper. The settlements cover an estimated 900,000 active and retired doctors.

"These documents are just hundreds of pages of legalese unless they are enforced," said Deborah Winegard, MAG's general counsel. "Sitting in my office here at MAG, I don't know what is going on in the doctors' offices."

Texas Medical Assn. President Bohn Allen, MD, agrees that individual physicians raising concerns will be what holds the health plans' feet to the fire. And he is encouraged that the Miami federal court that approved the settlements will continue to be involved in enforcing them for four years.

"We think this will help level the playing field," Dr. Allen said.

What doctors should look for

The class-action settlements doctors signed with Aetna and CIGNA in 2003 offered some monetary relief for claims filed in the past decade.

"But we certainly think the injunctive relief going forward is the bigger of the two," said Catherine Hanson, CMA general counsel.

Issues might vary from state to state, she said. If state laws are more stringent than the settlement terms, the state laws would apply. Here are some areas in which physicians should see changes:

  • Evaluation and management codes will not be automatically downcoded.
  • CPT coding edits must comply with key guidelines in the American Medical Association CPT manual.
  • Modifier 25 should be separately identified and paid. The same goes for modifier 59. Supervision and interpretation codes are separately identified and paid. Add-on codes are eligible for separate treatment.
  • Aetna physician fee schedules will be available online by Dec. 31. CIGNA will make its fee schedules available via e-mail.
  • Fee schedules can be changed only once a year.
  • Medically necessary treatment will be determined by a physician exercising clinically prudent judgment with generally accepted medical practice standards. Less expensive alternatives are allowed only when they are "at least as likely to produce equivalent therapeutic or diagnostic results."
  • Credentialing of new physician group members will be done within 90 days of the application. Physicians can submit applications before employment starts.

How to report problems

All parties involved in the settlement are trying to make it simple for doctors to resolve concerns.

Forms and step-by-step information about lodging a complaint are available on the HMO Settlements Web site (link).

The AMA and state medical societies also are posting the information on their Web sites. Many state medical societies will field calls from physicians who believe they have encountered problems.

Physicians can file two types of disputes -- one for external billing and another for compliance.

Physicians should use the external billing dispute if they are concerned about the way the company applied CPT codes to their claims or if they don't agree with the payment rules used. This process is also used to question the reimbursement methodologies used for a patient's specific situation, to dispute a medical necessity decision or to challenge Aetna's or CIGNA's request for records if a physician believes the request causes a demonstrable, undue burden.

To file a dispute, physicians will need to submit a request form, supporting documentation and filing fee to HAYES Plus Inc., the Pennsylvania company handling external billing disputes.

But not all disputes will fall into that category.

Physicians who believe that Aetna or CIGNA violated the actual terms of the settlement can lodge a compliance dispute. Doctors need to fill out a compliance dispute form available on the HMO Settlements Web site and submit it along with supporting documentation to Compliance Dispute Facilitator Julia Smeds Stewart.

Physicians who are part of medical societies that have signed on to the agreement also have the option of letting their medical society handle the compliance dispute. A list of those societies is available at the HMO Settlements Web site.

Stewart, who acts as the physician's or medical society's representative, will review the dispute. If she finds it valid, she will work with Aetna or CIGNA to resolve it. If the companies turn her down, she can go to a dispute resolution officer. If the physician is still unhappy with that ruling, the dispute can go to U.S. District Court Judge Federico Moreno, the federal judge in Miami who approved the settlement and continues to oversee physicians' cases against other managed care companies.

"I'm here to give teeth to the settlement," Stewart said. "I'm ready for the mail."

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Where to go for answers

Compliance concerns If you believe that Aetna or CIGNA is not complying with the settlement agreement, you can contact the compliance dispute facilitator with a request form and supporting documentation. Request forms and step-by-step instructions can be found online (link). Then send information to:

Julia Smeds Stewart
Aetna Compliance Dispute Facilitator or
CIGNA Compliance Dispute Facilitator
White Arnold Andrews & Dowd P.C.
2025 Third Avenue North, Suite 600
Birmingham, AL 35203

External billing disputes If you have an external billing or medical necessity dispute for claims filed with Aetna or CIGNA after the settlements took effect, you can file a request form, supporting documentation and a filing fee to challenge the decision. Request forms and step-by-step instructions can also be found online (link). (At press time, CIGNA forms were expected to be posted the week of July 19.) Send information to:

Aetna settlement or CIGNA settlement
HAYES Plus, Inc.
157 S. Broad Street, Suite 400
Lansdale, PA 19446
Phone: 215-855-0615

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Medical societies that can file disputes

Medical societies that signed on to the lawsuits and settlements with CIGNA and Aetna have standing in the court to file compliance disputes on behalf of their physicians. Here is a list of those signatory medical societies at press time.

Medical societies that were original plaintiffs:

Alaska State Medical Assn.
California Medical Assn.
Connecticut State Medical Society
Denton County Medical Society (Texas)
El Paso County Medical Society (Colorado)
Florida Medical Assn.
Medical Assn. of Georgia
Hawaii Medical Assn.
Louisiana State Medical Society
Nebraska Medical Assn.
New Hampshire Medical Society
Medical Society of New Jersey
Medical Society of the State of New York
North Carolina Medical Society
South Carolina Medical Assn.
Northern Virginia Medical Societies
Tennessee Medical Assn.
Texas Medical Assn.
Vermont Medical Society (CIGNA only)
Washington State Medical Assn.

Medical societies that signed on after the settlement was reached:

Medical Assn. of the State of Alabama
American Assn. of Practicing Psychiatrists
American College of Emergency Physicians
American Psychoanalytic Assn.
Arapahoe-Douglas-Elbert Medical Society (Colorado)
Arkansas Medical Society
Clear Creek Valley Medical Society (Colorado)
Colorado Medical Society
Medical Society of Delaware
Psychiatric Society of Delaware
Denver Medical Society (Colorado)
Medical Society of the District of Columbia
Harris County Medical Society (Texas)
Massachusetts Medical Society
Massachusetts Psychiatric Society
Mississippi State Medical Assn.
Ohio State Medical Assn.
Oklahoma State Medical Assn. (Aetna only)
Pennsylvania Medical Society
Rhode Island Medical Society
Medical Society of Virginia

Source: HMO Settlements Web site

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Dialing in

Julia Smeds Stewart, Aetna and CIGNA compliance dispute facilitator, hosts compliance calls twice a month to update physicians on the status of compliance disputes, the settlements with Aetna and CIGNA, and the status of the ongoing lawsuits against other companies.

To receive an e-mail alerting you to when the phone calls are held and to receive the toll-free number and access code to be a part of the call, contact Stewart or Laura Beth Christian at 205-323-1888.

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External links

Aetna and CIGNA settlements, including forms physicians can print (link)

List of medical societies that signed on to the agreement and can bring compliance disputes on behalf of member physicians (link)

AMA resources on the Aetna and CIGNA settlements (link)

Updates from the law offices of Archie Lamb, co-lead counsel representing physicians and medical societies in the managed care lawsuits (link)

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