Aetna, CIGNA settlements promise improved claims processing, better relations with physicians

Aetna and CIGNA recently settled their parts of a class-action lawsuit brought against them and several other national or regional health care insurers, signing agreements that could result in industry-leading improvements. The lawsuit, representing over 900,000 physicians, alleges that the health care insurers improperly denied, delayed or reduced reimbursement to physicians.

As part of their separate settlement agreements, Aetna and CIGNA have agreed to make numerous changes in their business practices, such as making their payment rules, fee schedules and claims processing systems clearer to physicians, stopping the practice of automatically bundling or downcoding codes submitted for covered services, and establishing independent external review boards for resolving billing and medical necessity disputes.

Aetna and CIGNA have also agreed to provide reimbursement to the plaintiffs totaling $100 million and $70 million, respectively. In addition, Aetna will provide $20 million and CIGNA will provide $15 million toward the creation of a foundation to promote high-quality health care.

Other health care insurers named in the class-action suit include Anthem, Coventry, Health Net, Humana, Paci-fiCare, Prudential, United Healthcare and Wellpoint. Their trial date is scheduled for Sept. 13, 2004.

Settlement compliance

If physicians or signatory medical societies believe that either Aetna or CIGNA have violated the terms of the settlement agreements, they may file a compliance dispute claim. Complaints should be submitted to the court-appointed compliance dispute facilitator within 30 days of the dispute. (Download the Aetna compliance dispute claim form at http://www.hmosettlements.com/Detail.aspx?PID=8 and the CIGNA form at http://www.cignaphysiciansettlement.com/documents.htm.) The compliance dispute facilitator in the Aetna case is Julia Smeds Stewart, JD, White Arnold Andrews & Dowd PC, 2025 Third Avenue North, Suite 600, Birmingham, AL 35203; 205-323-1888; jstewart@waadlaw.com. The compliance dispute facilitator in the CIGNA case had not been named at press time. Visit http://www.cignaphysiciansettlement.com for updated information.

PRACTICE PEARLS from here and there

Reduce errors with incentives

Error reduction begins with open error reporting. To encourage your staff to report errors, reward them with simple incentives. For example, the Cleveland Clinic health system sends thank-you notes – including free pizza coupons – to staff members who take the time and effort to report errors. Such incentives demonstrate that the organization is committed to learning from errors and is not seeking to assign blame.

– Advancing Patient Safety in U.S. Hospitals: Basic Strategies for Success. Rockville, Md: United States Pharmacopeia; 2004.

Longer waits for non-HIPAA-compliant claims

Any non-HIPAA-compliant Medicare claims submitted after July 1 will be treated as paper claims and subject to a 26-day waiting period, versus a 13-day waiting period for electronic claims, according to the Centers for Medicare & Medicaid Services (CMS). This announcement modifies the contingency plan CMS enacted last October that temporarily allowed physicians to submit non-HIPAA-compliant claims and still benefit from the shorter waiting period. CMS says the change is intended to encourage greater compliance with HIPAA formats and is “a measured step toward ending the contingency plan for all incoming claims.”

Physicians take steps to boost incomes

Financial pressures, such as lower reimbursement rates and increased liability and labor costs, are leading physicians to look for new ways to increase their incomes, according to a study by the Center for Studying Health System Change published in the March/April 2004 Health Affairs. The study found that some physicians are “aggressively” trying to increase their fees by dropping or threatening to drop health plan contracts, increasing patient volume by adding ancillary services and limiting less profitable services. The authors urge policy makers to “consider restructuring incentives to protect access to care and contain use, while acknowledging the real revenue and cost pressures that physicians face.”

DoctorsKnow.us no longer

DoctorsKnow.us, a Web site listing the names of approximately 100,000 patients with litigious pasts, voluntarily shut down amid public criticism after being featured recently in the Wall Street Journal. The Web site was launched last November by a Dallas-area radiologist who had previously been involved in two malpractice cases. Those who opposed the Web site said it could be used to deny care and blacklist innocent people. The Web site’s creator said it was intended to deter frivolous lawsuits.