Vigilance aids class-action claims

The more disputes that physicians file, the better case attorneys say they will have when trying to enforce compliance with the HMO settlement.

By Mike Norbut — Posted July 18, 2005

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Chicago -- Physicians, who were the engine behind the class-action lawsuits filed against the country's largest HMOs, also will be the most important compliance officers when it comes to ensuring the companies live up to their settlement agreements, attorneys representing the doctors in the lawsuits said last month.

Physicians and state medical society officials learned the latest details of their cases against insurance companies from the attorneys during a multi-district litigation conference at the American Medical Association Annual Meeting last month. Reaching settlement agreements with Aetna and Cigna Healthcare in 2003, it seems, was just the beginning of the battle, attorneys said.

Between fighting through red tape to receive money doctors have coming to them from the settlements and arguing about claims that have been denied, the administrative hassles are still very much a part of dealing with managed care companies, attorneys said.

Documenting the disputes

Physicians, however, can help alleviate those hassles by being vigilant in recording their compliance disputes, said Nick Roth, a Decatur, Ala.-based attorney. Many doctors may be experiencing problems in receiving payments for their claims, but they aren't bothering to file appeals, Roth said. They either expect other physicians to file similar complaints, or they are dissuaded by the time-consuming process, he said.

"If we do start having these appeals, we get the history of overturned claims," Roth said. "That goes to the advisory boards, which makes a difference. It lets us go in and say there's a systemic problem."

Aetna and Cigna both settled their cases with physicians in 2003, agreeing to cash payments and administrative changes that would make it easier for physicians to receive payment on their claims.

Settlement terms also spelled out ways physicians could dispute denials or the way the companies applied their payment rules.

Doctors who feel CPT codes were misapplied can file an external billing dispute, while those who think Aetna or Cigna violated the terms of the settlement can file a compliance dispute. All forms are available at the HMO Settlements Web site (link)).

Complaints regarding the Cigna settlement generally trace back to a processing backlog on past claims, while there have been several complaints regarding Aetna's ability to comply with its settlement going forward, lawyers said.

"It has been a full-time job taking Aetna to task for how they're handling the settlement," said Julia Smeds Stewart, a Birmingham, Ala., attorney and compliance dispute facilitator for the cases. "The more disputes we get in, the more we will hold their feet to the fire."

Stewart said she is involved in monthly mediation sessions with Aetna officials, where they discuss disputes made by doctors on what they believe to be bundling or downcoding strategies that are prohibited by the settlement agreement.

Stewart said once she receives completed dispute forms, she checks the complaining physicians' names against a database to make sure they have not opted out of the agreement, and then she sends the complaints to the insurers for comment.

"I can tell you [Aetna] has not recognized one of them," she said.

Aetna officials maintain the company is living up to its end of the agreement, but the disputes physicians have made are beyond the scope of the settlement. William Popik, MD, Aetna's chief medical officer, also reminded physicians to be patient.

"This serves as a great example of when you enter into a compliance arrangement, and you're dealing with 9,000 CPT codes and several million code combinations, orchestrating changes we are committed to can present a challenge," Dr. Popik said.

Cigna spokesman Wendell Potter offered similar sentiment, saying the company is committed to working with physicians according to the settlement terms.

"Part of the issue is some things take time to implement," Potter said. "We have every intent to live up to the settlement and we're making significant progress toward doing that."

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Trial date pushed back for suit against large insurers

Chicago -- The trial date in the class-action lawsuit pitting more than 900,000 physicians against some of the nation's largest insurance companies has been pushed back from Sept. 6 to Jan. 23, 2006.

The date of the trial, to be held in U.S. District Judge Federico Moreno's courtroom in the Southern District of Florida, was changed because of recent settlements and some motions that have been filed but remain unresolved, said Archie Lamb, co-lead counsel for the physicians and medical associations that filed the lawsuits.

California-based Health Net, which along with Prudential Insurance Co. of America reached settlement agreements with physicians earlier this year, needed ample time to notify members of the class, Lamb said.

Meanwhile, PacifiCare Health Systems, one of the remaining defendants, had not yet been heard on one of its motions, he said.

The delay will allow more time for settlement discussions, which received a boost from the recent agreements with Health Net and Prudential.

"The settlements were important not so much for their size, but what it indicated to the judge," primarily that discussions with the health plans were still in motion, Lamb said.

Aetna and Cigna Healthcare preceded Health Net and Prudential in settlement agreements. The remaining defendants besides PacifiCare include Coventry, Humana, UnitedHealthcare, and WellPoint Health Networks. The doctors allege that the HMOs conspired to systematically underpay physicians by downcoding and bundling claims.

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