Physician feedback encouraged as health plan settlement shakes out

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."