Aetna contract changes mailed to physicians

The addendum explains settlement agreement details, including a description of who determines medically necessary care.

By Mike Norbut — Posted Sept. 26, 2005

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More than 400,000 physicians can expect to receive contract changes from Aetna this month spelling out specifics of a settlement agreement forged between the insurer and organized medicine groups in 2003.

While many of the contract changes have been in place since the settlement was approved, the documents arriving in physician mailboxes reiterate some of the more important provisions, such as medically necessary care and the definition of a clean claim, said Tom Young, Aetna's internal compliance officer for the settlement.

"The agreement began an era of cooperation with physicians that has enabled many positive changes in our interactions with physicians," Aetna Chair and CEO John W. Rowe, MD, said in a statement. "Since 2003, we have simplified administrative practices for physicians, increased transparency of policies and processes, and worked collaboratively to encourage greater use of evidence-based guidelines in medicine."

Physician groups involved in the litigation are pleased with the way the contract addendum describes the authority a doctor has in determining a patient's care. It says patients are entitled to medically necessary care as determined by a physician who follows generally accepted medical practice standards. Aetna can only require a less costly alternative if it's "at least as likely to produce equivalent therapeutic or diagnostic results," according to the addendum.

The contract changes also reaffirm the value of the physician-patient relationship, a provision that was emphasized in the settlement agreement.

"Now, physicians can spend less time worrying about their businesses and more time caring for their patients," California Medical Assn. President Michael J. Sexton, MD, said in a statement. "For physicians, the new contract means that Aetna will pay them, on time, for the services their patients need."

Doctors filed class-action lawsuits against the nation's largest HMOs, accusing the companies of conspiring to systematically underpay physicians by downcoding and bundling claims. Aetna was the first insurer to settle a lawsuit. The agreement called for Aetna to pay an estimated $170 million, including payments to physicians and funding for a foundation.

The settlement also detailed changes Aetna needed to make going forward to make the claims process less onerous for physicians. Doctors who believe the insurer is not living up to the agreement can file a compliance dispute. The form is available at the HMO Settlements Web site (link).

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