This settled class-action lawsuit was a New Jersey state court case that was pending for some time. MSNJ was not a party in this action and has not been involved in its prosecution. MSNJ had no role in the settlement negotiations.  MSNJ is, however, investigating how this class-action settlement will affect New Jersey physicians.

As a reminder, MSNJ is an active party to a national class-action lawsuit against Horizon which is currently in court-ordered mediation in Florida. The mediation order is set to expire in mid-November. MSNJ and Horizon are engaged in good-faith settlement negotiations pursuant to the court’s mediation order. We will keep members informed of significant developments in the pending, national class-action lawsuit against Horizon.

Counsel to MSNJ and Horizon have reached an agreement in principle, which is currently being reviewed by MSNJ and Horizon for approval. This agreement, if approved, would end a class-action lawsuit against certain defendants, including Horizon, brought in federal court in Florida by MSNJ and several other state and county medical societies. The lawsuit alleges unfair business practices by various health insurance plans.

The relief proposed in the MSNJ–Horizon settlement is consistent with the relief achieved in other class action settlements with Aetna, Cigna, Healthnet, Humana, and Wellpoint. The parties will meet to work out local issues, and a final agreement is expected by December 31, 2006.

It is important for doctors to know that the agreement-in-principle substantially addresses many of the issues raised by physicians who oppose the proposed settlement in the Sutter v. Horizon matter that was announced several weeks ago. Sutter v. Horizon is a separate, state-court case, to which MSNJ is not a party. Any actions taken by individual physicians in the Sutter case will have no impact on their rights in the MSNJ–Horizon settlement.

Attached are Excel spreadsheet physicians should use to submit claims, the certification, and the communications piece on modifier 25.

The Aetna national class-action settlement agreement obligated Aetna to recognize add-on codes, as designated by cpt, to be eligible for separate payment and not subject to multiple procedure logic. However, Aetna’s systems did not recognize certain codes related to cad mammography services (cpt codes 76082 & 76083) and myocardial perfusion testing services (cpt codes 78478 & 78480) and, consequently, denied payment. Numerous physicians filed compliance disputes alleging violations of the Aetna settlement agreement. Aetna has since corrected its systems to recognize the cad mammography add-on codes (as of April 1, 2005) and myocardial perfusion testing add-on codes (as of May 13, 2005).

Aetna and representatives from a number of state medical societies have reached an agreement settling this add-on code dispute that is available to affected physicians. Affected physicians must take action by July 14, 2006 to be paid for these services. Aetna will process new or resubmitted claims for the following:

CAD mammography services (CPT codes 76082 & 75083) provided to Aetna members between January 1, 2004 and March 31, 2005; and

Myocardial perfusion testing services (cpt codes 78478 & 78480) provided to Aetna members between January 1, 2004 and May 12, 2005.

Physicians can resubmit previously denied claims by listing the claims on a spreadsheet and submitting them to Aetna via secure e-mail. New claims may be submitted electronically or via paper, using current standard procedures. Key information, instructions, and forms can be found on www.aetna.com on the “Doctors and Hospitals” main page under “Features” in the lower right corner. Click on the link entitled “Add-On Codes Claims Payment.” For further information, call the Aetna Provider Service Center at 888-632-3862 for Indemnity and ppo-based benefits plans or 800-624-0756 for hmo benefits plans.

On May 24, 2006, msnj representatives and the New Jersey Academy of Family Practice met with Aetna regarding the recovery of purported overpayments to physicians with captitated contracts. At the meeting we reviewed the notices Aetna was sending to the affected practices and found the notice deficient, in that the information provided to physicians was not sufficient to allow independent verification of an overpayment. We have written to Aetna Compliance Officer Tom Young [here’s the letter]. [June 8, 2006]

Aetna will be writing to physicians whom they have overpaid on claims submitted between Marcy 1, 2005, and December 31, 2005. We have copies of letters covering two circumstances.

1. Aetna inadvertently issued both capitation and fee-for-service payments that were already covered by capitation. They will deduct the amount of the overpayment from physicians’ July 2006 capitation payments.
2. Aetna inadvertently issued both capitation and fee-for-service payments that were already covered by capitation. They will deduct the amount of the overpayment from physicians’ monthly capitation payments, up to 50% of the total capitation amount per month.[May 11, 2006]

Policy Addendum

In October 2005 Aetna sent a letter to physicians that “outlines, reinforces and clarifies selected provisions” of the 2003 Physician Settlement Agreement. [November 28, 2005]

MSNJ Reaches Agreement with Aetna in Class-Action Lawsuit [May 22, 2003]

The claims period against Aetna has closed and many physicians are receiving checks for the monetary compensation portion of the settlement agreement. More importantly, Aetna is improving several business practices as a direct result of msnj’s continued intercession and the class-action lawsuit settlement agreement. One change, involving coding policy and reimbursement, was driven by information and advice from msnj. The other change involves Aetna’s voluntary extension of the settlement agreement for an additional year.

First, Aetna will pay for the following codes with dates of service beginning April 1, 2005:
76082: Diagnostic Mammography; and
76083: Screening Mammography; and
77336: Radiation Physics Consult.

Also effective with an April 1 date of service, Aetna will allow payment of the ophthalmic imaging code, 92135, for glaucoma and retinal diseases (but not routine screening of the general population).

Effective June 15, 2005, Aetna will allow separate reimbursement of the following codes:
76872/76942: Rectal Ultrasound & Biopsy
78478/78480: Ejection Fraction (add-ons).

Second, Aetna has stated “because it is consistent with our mutual goals, we have agreed to extend the substantive provisions of the settlement agreement for an additional year, to June 2, 2009.” Read about the coding policy and extension of the settlement agreement in a letter dated April 4, 2005, to S. Manzoor Abidi, md, President, msnj, from Joseph F. Dougherty, md, Aetna, Medical Director. Msnj is pleased to convey this agreement to our members.

The deadline for filing claims against CIGNA to recover monetary damages was February 18, 2005.  Based on the terms of the settlement agreement the signatory medical societies (including msnj) believed that distributions for Category A claims (pro rata shares) would be made in March. This did not occur so msnj and other signatory medical societies urged the medical societies’ compliance team to take action.  Physicians should have received their distribution checks in the mail. The base amount is $166.14. [July 11, 2005]

The CIGNA press releases is available at Settlement Between Physicians and CIGNA Approved  [February 3, 2004]

AMA Supports CIGNA Settlement with Nation’s Physicians [February 3, 2004]

Medical Society of New Jersey Reaches Agreement with CIGNA [September 4, 2003]