Managed Care - Class Action Lawsuits
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Background: MSNJ has been a leader among prominent state medical societies by filing and prosecuting class-action lawsuits against the major national healthcare insurers.The lawsuits allege that the major healthcare insurers were engaging in a pattern of unfair business practices to deny and delay payments to physicians. The following companies have settled to date:
- Aetna
- CIGNA
- HealthNet
- Prudential
- Anthem/WellPoint (Well Choice in NJ)
- Humana
Unfortunately, the United Healthcare/Oxford class-action lawsuit was dismissed, but that decision is being appealed. In addition, the lawsuits against most of the Blues (including Horizon) is pending in Florida. Parties to the Blues lawsuit are currently conducting good faith negotiations pursuant to a court order mandating mediation.
The national class-action settlement agreements contained retrospective relief in the form of cash payments (a share of the settlement fund was paid to physicians who filed claims) and prospective relief. The prospective relief was designed to require sweeping changes in the business practices of the healthcare insurers on a forward-going basis. The key provisions of the prospective relief specify rules for claims processing and payment, as well as rules for disclosure of how the claims process works. The prospective relief is enforceable up to the termination date of the settlement agreements.
The Aetna, CIGNA, and HealthNet settlement agreements are in effect and enforceable. We routinely advise members of enforcement trends in MSNJ e-News and Physician Advocate.
Strategy: MSNJ's strategy in pursuing the national class-action lawsuits is to build on the success of each settlement. We aim to improve the settlement agreements, both in terms of the substantive provisions and in terms of the process. MSNJ is also attempting to "standardize" the processes that the settling healthcare providers have agreed to. Through legislation we are attempting to "raise the bar" of all healthcare insurers and level the playing field among companies so that all healthcare insurers will have to adopt fair business practices and processes. This is also important because the agreements have expiration dates and then will no longer be enforceable.
Compliance: Under circumstances in which New Jersey law and the class-action settlement terms address the same issue, the “best" term prevails. If New Jersey law is better than the terms of the settlement agreements, New Jersey law prevails. If the class-action settlement term is better, the settlement term prevails. This is good for members because we achieve the best possible result for New Jersey physicians. However, this will be a challenge over the next several years because we have a mosaic of terms from which to select the best relief.
This web site is designed to help physicians and practice managers identify the best terms. Whenever possible, the “Managed Care Payment Issues” pages will outline the New Jersey statutory provisions and the corollary terms contained in settlement agreements.
MSNJ encourages all members to become familiar with the terms of the class-action settlement agreements and to file compliance disputes for any conduct that violates the agreements. We will keep you up to date on compliance trends and assist you in determining whether there is a viable compliance dispute. It is very important that physicians make the insurers live up to their agreements.
Educational Material: MSNJ has published a class-action lawsuit compliance guide and is giving a series of seminars on how to enforce compliance with the national class-action settlement agreements. To request a compliance guide, e-mail mmartins@msnj.org.
Web Site Links:
Compliance Toolkit
Settlement Facilitators:
Aetna & CIGNA
Deborah J. Winegard
c/o Doffermyre Shields Canfield Knowles & Devine
1355 Peachtree St. Suite 1600
Atlanta, GA 30309
(404) 881-8900 (telephone)
(404) 881-3007 (fax)
dwinegard@gmail.com
HealthNet
Cameron C. Staples
Neubert Pepe & Monteith, PC
195 Church Street, 13th Floor
New Haven, CT 06510
Telephone: 203-821-2000
Fax: 203-821-2008
Email: healthnetcomplaint@npmlaw.com
Examples of Successful Compliance Disputes:
- All-Products; allowing physicians with fee-for-service plans to terminate participation in capitated plans (Aetna)
- Add-on Codes; reimbursing for wrongfully denied add-on codes for certain cardiology and ob/gyn procedures (Aetna)
- EKG (CPT code 93010); allowing reimbursement when billed with an emergency room evaluation and management service (CPT codes 99281-99285) with or without modifier 25 (Aetna)
- Modifier 25; allowing reimbursement for a list of evaluation and management codes billed (Aetna)
- Over-Payment Recovery (Aetna)
- Report from Aetna Settlement Facilitator on successfully concluded disputes.
- Vaccine Reimbursement; requiring increases in the fee schedule in North Carolina (CIGNA)