Make Insurers Keep Their Promises

The nation's largest for-profit health insurers have agreed to change the way they do business because of the class-action federal lawsuits that the Texas Medical Association and other medical societies across the country filed against them. However, physicians need to remain vigilant to make sure the companies comply with the terms of the settlements of the lawsuits.

Physicians who believe Anthem/WellPoint (UniCare), Health Net, Humana, and Blue Cross and Blue Shield have violated their settlement agreements should file a compliance dispute form, says the Physicians Advocacy Institute (PAI), which enforces the settlements on behalf of physicians. The forms are available in the Compliance Center of the  HMO Settlements Web site . There is a separate compliance form for each company. There is no cost to file a dispute. TMA helped create PAI and is an active member, assisting in enforcement of the settlements.

Counting just the settlements with Aetna, CIGNA, and Anthem/WellPoint, Texas physicians have recovered nearly $11 million in repayment for previous abuses so far. PAI adds that physicians across the country have collected millions of dollars by using the compliance dispute process. For example, physicians collected more than $12 million for previously denied CAD mammography and myocardial perfusion add-on codes. Physicians also have been saved from repaying millions of dollars in alleged overpayments.

The latest settlement to take effect involves Blue Cross and Blue Shield. As a result, Blue Cross and Blue Shield plans:

  • May not seek overpayment recovery beyond 18 months (six months for insured plans) unless fraud is implicated;
  • Must use a clinically based definition of medical necessity;
  • Must adhere to most CPT coding rules, including payment for evaluation and management codes appended with modifier 25 and payment for add-on codes;
  • Must provide 90 days advance notice of material adverse changes;
  • May not require physicians to participate in all products, and
  • Must disclose their methodology for determining "usual, customary, and reasonable" amounts.

For more information, log on to the RICO Case Materials section of the TMA Web site, the  HMO Settlements Web site , or the  AMA's Health Insurer Settlements Web page . You also may contact the compliance dispute facilitators - Deborah Winegard  for Blue Cross and Blue Shield and Humana disputes, or Cameron Staples for the Anthem/WellPoint and Health Net cases.

The TMA Hassle Factor Log program, as well as the TMA Office of the General Counsel , also can help you.


Action , May 15, 2009

Last Updated On

July 24, 2010