Aetna to Pay $120 Million in Claims Dispute

Aetna's creation of a $120 million fund to pay physicians for out-of-network claims moved closer to reality last month when a New Jersey federal judge tentatively approved a settlement of the class action lawsuit by the Texas Medical Association and its organized medicine partners. Final approval is scheduled for March.

The $120 million will come in two parts. Half will cover claims from physicians and patients who qualified to be parties to the case but do not have the documentation to show how much Aetna owes them. It also covers attorneys' fees and administrative costs. The second will pay claims from physicians and patients who have the documentation.

The agreement, which was reached last December, calls for a settlement administrator to officially notify physicians of the settlement by Dec. 28. The notice will tell physicians what they need to do to file a claim. Claims must be submitted by March 28, 2014. The settlement applies to physicians who were out-of-network providers "at any time" from June 3, 2003, through Aug. 30, 2013, the date the judge preliminarily approved it, and whose claims were not paid in full by Aetna.

TMA, the American Medical Association, and the medical societies of California, Connecticut, Florida, Georgia, North Carolina, New Jersey, New York, Tennessee, and Washington sued Aetna in 2009 over its use of databases licensed from Ingenix, a UnitedHealth Group Inc. subsidiary. Ingenix underpaid physicians for out-of-network services, the lawsuit said. It also challenged other ways Aetna determined out-of-network payment rates and accused Aetna of failing to disclose how it figured those rates. A patient filed a similar suit in 2007.

Aetna, United, and other insurers agreed to stop using the Ingenix database in settlements with the New York State Attorney General in 2009. That settlement created FAIR Health to take over and improve the database and establish transparent, current, and reliable health care charge information.


Action, Sept. 17, 2013


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