CIGNA's 2003 settlement agreement under the national class-action antiracketeering case expired Sept. 4, ending CIGNA's obligation to comply with the terms of the settlement. Expiration of the settlement will not affect physicians who already have submitted valid claims for damages from the Claim Distribution Fund and are waiting to be paid.
Physicians who have contracts with CIGNA should review their agreements and contact their provider representatives to determine how the end of the settlement terms will affect their business relationships with CIGNA. Many Texas physicians have received new contracts from CIGNA that take effect on Oct. 1. It would be prudent to review this new contract since the settlement will no longer control physicians' relationship with CIGNA.
The Physicians Advocacy Institute (PAI) is trying to persuade CIGNA to voluntarily continue most of the business practices required by the settlement. The PAI is an organization of state medical society executives, including Texas Medical Association General Counsel Donald P. Wilcox, JD, and a physician plaintiff that makes sure defendants in the lawsuit comply with the settlement terms. The PAI says CIGNA has indicated that some practices will remain, some will change, and others may change:
Business Practices That Will Remain in Effect
CIGNA has voluntarily agreed to continue to make its fee schedules and payment rules available to physicians. CIGNA has also agreed to continue adhering to the settlement's coding rules, including its prohibition on downcoding evaluation and management codes and the payment of reasonable fees for vaccines and injectibles. In addition, CIGNA has agreed to continue to give physicians 180 days to file timely claims and not seek recovery of overpayments beyond 12 months. These were some of the most important provisions of the settlement Agreement for physicians.
Business Practices That May Change
Although CIGNA has indicated it intends to maintain the settlement's clinically-based definition of medical necessity and its prohibition against all products requirements, CIGNA contracts recently sent to physicians in some markets allow the medical necessity definition to be changed and contain all-products clauses. In addition, although CIGNA does not currently anticipate revising its fee schedules more than once a year, it has reserved the right to do so.
Business Practices That Will Change
CIGNA has indicated it will no longer pay interest on late paid claims for patients of self-funded plans, that it may contract with rental networks, and that it may no longer recognize assignment of benefits.
Log on to www.texmed.org/rico or www.hmosettlements.com to view the CIGNA settlement provisions.
Physicians still have until Dec. 1 to resubmit CAD mammography claims previously denied by CIGNA. Eligible claims must involve CPT Codes 76082 or 76083 as add-on codes with 76090-76092, and have been submitted between Jan. 1, 2004, and Oct. 10, 2004. Resubmitting claims is simple: Complete the spreadsheet posted at link above.
The Aetna, Health Net, Humana, and Anthem/WellPoint settlements remain in effect. The Blue Cross and Blue Shield settlement, which includes Blue Cross and Blue Shield of Texas, is expected to take effect later this year.
Physicians who believe health care payment plans aren't adhering to a settlement agreement can contact the plan's compliance dispute facilitator to determine whether to file a complaint. Contact information for each plan's compliance dispute facilitator, as well as a step-by-step guide to the compliance dispute process, is available at www.texmed.org/rico and www.hmosettlements.com .
And, TMA's Hassle Factor Log program and payment advocacy staff can help physicians with the compliance dispute process. TMA members can submit a Hassle Factor Log online, by mail, or via fax. To get started, visit www.texmed.org/hassle , or call Payment Advocacy at (800) 880-1300, ext. 1414, or (512) 370-1414, and you will be directed to the appropriate reimbursement specialist.
TMA has helped Texas physicians receive reimbursement for millions of dollars in claims from settlements with other defendants in the RICO case, including Aetna, Health Net, Prudential, Anthem/WellPoint, Blue Cross and Blue Shield, and Humana. Texas physicians have received at least $11 million to date in cash payments from the settlements of the national class action, antiracketeering lawsuits against Aetna, CIGNA, and WellPoint. The payments to date include $7.5 million to Texas group practices and $2.5 million to individual Texas physicians.