Keep Your Guard Up

Compliance Disputes Make RICO Settlements Successful  


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Law Feature - April 2006  


By  Erin Prather
Associate Editor

American author Lyn Abbey once penned, "Persistence pays and so does a willingness to follow directions." Physicians should keep that in mind when they suspect that Aetna or CIGNA is violating the terms of the settlement of the Racketeer Influenced and Corrupt Organizations Act (RICO) lawsuit against for-profit HMOs.

In agreeing to change how they handle physician reimbursement, both companies said they would simplify claims submission and processing and reduce administrative burdens on doctors and their staff. You should file a complaint if they don't.

Texas Medical Association Director of Health Care Financing Teresa Devine says physicians must file compliance disputes to fully benefit from the lawsuit and settlements.

"Texas physicians have to hold the health plans accountable to the promises they made. The only way to do that is to identify issues where the health plans are not living up to the agreements," she said.

To help physicians with filing, TMA and other state medical societies active in the RICO Settlement Compliance Work Group have developed a Settlement Enforcement Toolkit. Located on the  and Web sites, the toolkit provides information about the settlements, compliance disputes, billing disputes, and perspective relief overviews. It also contains the forms physicians need to file a compliance dispute.

More than a hundred settlement disputes have been filed to date against CIGNA and Aetna. They are summarized in the last three pages of the Settlement Enforcement ToolKit and involve millions of dollars in claims.

The toolkit contains several examples of how Aetna and CIGNA are not following the settlement agreements. For example:

  • Aetna routinely denies reimbursement to emergency physicians treating patients with symptoms of acute coronary conditions requiring an electrocardiogram. The company denies the code (CPT code 93010: electrocardiogram with at least 12 leads, interpretation and report only) when billed in conjunction with an evaluation and management (E&M) code (CPT codes 99281-99285). This code is routinely denied even when the E&M code includes a -25 modifier indicating the E&M service and the 93010 procedure were separate and identifiable from one another. This violates settlement provisions that require Aetna to recognize both the E&M code and a service procedure code when appropriate clinical information is provided.
  • CIGNA advised an ophthalmologist that he must join its HMO networks to be allowed to participate in CIGNA PPO products. This is in violation of the "All Products" provisions of the CIGNA settlement. 

"Diligent About Everything"  

Ms. Devine warns physicians not to limit their complaints to the situations shown in the examples.

"There have been numerous complaints filed about those issues, but physicians need to be diligent about everything," she explained. "New disputes emerge every day, and it's up to physicians to ensure the health plans are not undermining the settlement."

You can file a complaint if you have not opted out of the settlement. It must be filed within 30 calendar days of the date the dispute arose. Either you or your office staff must complete the form, and you must sign it.

You must give specific facts about why you believe the health plan is not fulfilling its settlement obligations. Any supporting documents, including any correspondence with the health plan, also should be included.

The compliance dispute facilitator, Birmingham, Ala., attorney Julia Smeds Stewart, will determine the merits of the complaint. She can be reached by email at  or by phone at (877) 760-0157. TMA can help you with compliance issues. You can contact the TMA Office of the General Counsel or the Health Care Financing Department at (800) 880-1300 or (512) 370-1300 for help.

Aetna and CIGNA were the first of the 10 for-profit health insurance companies in the class action lawsuit to avoid a trial by settling with the plaintiffs. The suits charged the companies with racketeering by maintaining claims-processing practices and systems that lowered reimbursement.

Since then, Health Net, Prudential, WellPoint, and Humana also settled with the state medical societies and physician plaintiffs who represent the nation's 700,000 physicians in the case. Enforcement of these settlements are just now becoming final as interveners challenging the settlements have been satisfied or their challenges were unsuccessful. The value of the settlements exceeds $1.5 billion in retrospective and prospective relief.

Trial for the remaining defendants is scheduled for Sept. 18 in a Miami federal court. They include Coventry Health Care and UnitedHealthcare.

Erin Prather can be reached at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email at  


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