Insurance watchdogs push compliance with settlements: AMNews interviews Robert W. Seligson

Out of physicians' nearly decade-long legal fight against health plans' unfair reimbursement tactics arose the Physicians Advocacy Institute Inc.

The organization, whose board is made up of executives from nine state medical societies and a lead physician plaintiff, has been up and running since early 2006. Its mission: to fight for physicians to make sure health plans stick to the settlement terms.

The oversight entity was established with funds from the 2005 settlement with Prudential Insurance Co. of America -- one of eight similar class-action settlements reached with the country's major insurers, who agreed to alter the way they pay doctors. In all, the settlements amount to $2.5 billion, including cash, future payments and business changes.

Robert W. Seligson, the PAI's president, talked with AMNews about the organization's work to help doctors resolve claims and what lies ahead to keep up with managed care's evolving business practices.

AMNews: Briefly describe the PAI and its purpose.

Seligson: We took on managed care in court because there was no other recourse for physicians who were sick of all the administrative and payment games that insurers were playing. We haven't fixed every problem, but we sure got the health insurers to pay attention and to know that PAI means business, even when the settlements expire. Our purpose is to continue the momentum gained by the lawsuits and hold health plans accountable to the terms of the settlements and to give physicians the tools necessary for them to maintain viable practices. ... We have a team of general counsels from state medical associations across the country watching for any signs of noncompliance by insurers. ... Compliance dispute facilitators are appointed by [the doctors' attorneys] and are physicians' advocates for each settlement.

AMNews: Has the PAI been successful in resolving physicians' claims disputes? How so?

Seligson: PAI, through its Compliance Committee, has helped resolve a number of important disputes. With Aetna, we were able to have ... [some] claims reprocessed ... secur[ing] an additional $12.5 million. ... With Cigna, compliance disputes resolved payments for vaccines and eliminated [certain code-blending] on the East Coast. A Cigna compliance dispute has allowed doctors to resubmit [some] previously denied [mammography] claims.

These examples show the compliance dispute process can work, but we need physicians to file disputes. Our purpose is to remind the insurers about what they agreed to and what it means to comply. There have been some tough discussions to get insurers to "remember" what they agreed to, but that's why the PAI exists.

AMNews: Is this just about recouping money for doctors or does the institute have a broader purpose?

Seligson: When all is said and done, physicians will have received over $500 million in monetary relief from these settlements. Health insurers feel this where it hurts: their bottom lines. But we have always been more focused on the prospective relief provided by the settlements and restoring fairness for doctors. ...

Our purpose is to give doctors tools to get ahead of the curve. Because doctors are focused on taking care of patients and running their practices 24/7, it is very difficult for them to stay on top of emerging health insurer initiatives until it is too late. We want to help physicians immediately react to ill-conceived, cost-cutting, hassle-enhancing initiatives by the insurers.

AMNews: Some physicians report ongoing hassles with getting insurers to follow the terms of the settlements. What are some challenges the PAI has dealt with, and are the health plans complying?

Seligson: There has been recalcitrance on the part of some health insurers to "embrace" the terms of the settlements and be pro-activist about complying. No court settlement is ever perfect, and that is why there is a compliance process that we have used to great advantage. For example, we required Aetna to totally revamp its physician contracts to adhere to the settlement. Major coding violations were corrected, and physicians were paid in arrears. But, yes, we are still experiencing problems with compliance, even as the Cigna settlement is about to end. Significant portions of the Aetna settlement have been extended until June 2008, so we will continue to enforce Aetna's compliance. However, we have learned a lot, and this knowledge will be put to good use in the remaining years of compliance activity with Humana, WellPoint/Anthem, Health Net and the BlueCross and BlueShield settlements.

We have called on the nation's largest health insurer that has not settled, UnitedHealthcare, to voluntarily adopt the terms of the settlements as a goodwill gesture to prove that United wants to turn around its relations with physicians. We have asked for ongoing communication and would like to evaluate United's pay-for-performance program.

AMNews: There is some concern that insurers are not in this for long-term change, especially with the inevitable sunset of the individual settlement agreements. What are the PAI's future plans to hold them accountable and address other potential abuses that may emerge?

Seligson: It is a safe bet that we will see health insurers revert to some presettlement tactics. However, smart health plans will recognize that it is good business to maintain improved relationships with physicians. We expect many of the "transparency" terms of the settlements to remain in place. We are engaged in active discussions with those insurers whose settlements will be expiring soon to encourage voluntary retention of all the settlement provisions. The PAI will not go quietly into the night just because a settlement ends. We do not expire when a settlement expires. ...

The most important initiative PAI is developing to help physicians control their own destinies will be the Claims Data Warehouse for physicians. Physicians must be able to analyze their own claims data within the guidelines established by the Federal Trade Commission and the Dept. of Justice. This is a massive undertaking that PAI believes can help physicians not only with health insurance claims in terms of accuracy and payment, but also with many of the pay-for-performance initiatives being thrust upon them. Insurers have been analyzing physicians' claims data for years. Why shouldn't physicians be able to analyze and dissect their own data the way the health plans do?