Worth the Effort: CIGNA List Has Much-Needed Claims Information

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Law Feature -- December 2004  

It's a lot of work and you may not think it's worth the hassle, but you really need to get a copy of the facilitation list that CIGNA HealthCare put together after it settled its portion of a federal antiracketeering lawsuit last year. The list will show you just how much you've been shortchanged over the past several years. It also will help you recoup some of the money you lost.

Because he obtained a copy of the list, Houston otolaryngologist Philip Matorin, MD, stands to get several thousand dollars, perhaps more than $30,000, he should have been paid in the first place had CIGNA not repeatedly bundled claims he and thousands of other physicians submitted.

"I think physicians owe it to themselves to at least request the facilitation list so they can actually see what was done to them," said Dr. Matorin, chair of the Harris County Medical Society Board of Socioeconomics. "This is our money. We provided the service, yet somebody else got all the benefits."

The list is different for each physician. See " How to Get a CIGNA Claims Facilitation List ."

CIGNA is making available more than $70 million as part of a settlement of its share of a federal lawsuit accusing it and other health insurers of systematically lowering and denying payment for legitimate claims. CIGNA agreed to spend hundreds of millions of dollars to change its claims-processing systems to make its business practices fairer to physicians. And, it has endowed a physician-controlled foundation that will study ways to improve patient care through better physician practices.

It's a tricky process, but physicians have two options for recovering money. They can file for reimbursement under Category A or under Categories One and Two of the Claim Distribution Fund (CDF). Recovery under Category A is a relatively simple process, but it offers limited reimbursement. Category One under the CDF is available to doctors whose payment was denied or reduced for 1,200 specified claim-coding and bundling edits. The CDF's Category Two claims are for similar editing reductions or denials, but involve unspecified codes. If you file under Category A, you can't file under the CDF.

The real money is in the CDF, but claims filed through this unlimited settlement fund require substantial documentation for each claim in each category. Dr. Matorin spent about 10 hours tracking down Category One claims in his computer system and learned that he was a "major victim" of bundling. He found about 70 instances of mispaid claims.

The facilitation list helped him determine how much he was owed in Category Two. The list Dr. Matorin received was 31 pages with almost 1,300 instances of improper bundling and withheld payments under Category 2. Other physicians may receive longer or shorter lists. Information on the facilitation list includes patients' names, dates of service, and procedure codes submitted, paid, and denied.

Dr. Matorin said the facilitation list provided enough information so he "didn't have to spend any time at all" in compiling the information he needed for Category Two claims. "That's a lot more efficient." He also said that although not required for Category One claims, the list is useful to physicians in determining which claims to file.

Dr. Matorin advises other physicians to get a copy of the list and start figuring out how much CIGNA owes them. "It's not going to eliminate all the work, but it's certainly going to help," he said.

Donald P. Wilcox, JD, Texas Medical Association general counsel, concurs with Dr. Matorin's advice. "You need to do this," he said. "This is money in the bank here. It could mean tens of thousands of dollars to physicians."

Mr. Wilcox says physicians can either file the claims for payment themselves or hire the Managed Care Advisory Group (MCAG) to help.

TMA has arranged a members-only discount with MCAG to help physicians determine the best course of action for recovering unpaid or underpaid claims from CIGNA. MCAG also will help identify and submit claims to CIGNA.

MCAG is offering its services to members of TMA, the American Medical Association, and certain other state medical societies. For more information on its services, see the MCAG Web site at www.mcaginc.com or call (800) 355-0466.


How to Get a CIGNA Claims Facilitation List

The facilitation list created by CIGNA HealthCare after settlement of the federal antiracketeering lawsuit is an important document for physicians to determine how much money they stand to recoup. The facilitation list will give you the information you need to determine how much reimbursement you should have received from the original claim.

But you must request a list from the settlement administrator. It can be ordered at www.cignaphysiciansettlement.com/contact.htm#RequestFacilitation . Information on the list is different for each physician.

According to Rylan J. Penning in the settlement administrator's office, only physicians or physician groups can request a facilitation list. If the physician or group hires an outside source to prepare and submit claims, the physician or group still must submit the request for the list.

Clicking on the Internet link listed above is the first step in creating the list. This notifies Mr. Penning via e-mail that the physician or group is requesting the records of the tax identification number they provide. Mr. Penning then will send you an e-mail that confirms that the request has been received and provides detailed instructions. It also will ask you to send in a signature page. This is required because the information on the list is confidential.

If a single physician is requesting the list, then only his or her signature is required. However, if the request is from a group, it must be signed by someone who has the authority to sign on behalf of the entire group, such as an administrator, chief executive officer, or owner.

Whereas the facilitation list is not meant to be an exhaustive list of all possible claims your practice could submit, it should aid you in determining any additional services from your practice that could be submitted for Category Two reimbursement. The list also is available by calling (877) 683-9363. Press "0" twice to reach an operator. If you should request the list by telephone, the operator will instruct you to fax a signature to accompany the oral request for the list.

Mr. Penning adds that facilitation lists are created off of the tax identification number physicians or physician groups use to submit claims to CIGNA. "Occasionally, a physician uses his or her Social Security number, but these instances are few and far between. Only submit the number that is for sure used to submit claims," he said.

For more information on the CIGNA settlement and what it means to you and your practice, log on to www.texmed.org/rico.

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