CLASS ACTION SETTLEMENTS
Humana 


Deadline to Submit For Humana Settlement: February 17, 2006
As part of the settlement, Humana has agreed to make a settlement payment of $40 million which, together with accrued interest from the Court Preliminary Approval Date (October 19, 2005), will be distributed to physicians who are members of the Class Action and who file a timely claim form. If the settlement is approved by the United States District Court in Miami Florida, the members of the Class will be entitled to payments in accordance with formulas described below.



Question: Who are members of the Class?
Answer:
Any and all Physicians, Physician Groups and Physician Organizations who provided Covered Services within the fifty (50) United States to any Plan Member or any individual enrolled in or covered by a plan offered or administered by any of the named defendants in the class action lawsuit or by any of their respective current or former Subsidiaries or Affiliates, in each case from January 1, 1990 through the Court Preliminary Approval Date (October 19, 2005). The defendant health plans in the class action include Aetna, Anthem, Coventry, CIGNA, Humana, HealthNet, United Healthcare, Pacificare, Prudential and Wellpoint.
(NOTE: The Excellus lawsuit was a separate class action in New York State court and was not part of the same lawsuit in United States District Court in Miami Florida)

Question: What if I never treated a Humana enrollee?
Answer:
Even if a physician has never treated a Humana enrollee, the physician is entitled to claim the Base Amount if the physician is a Class Member and did not opt out. Check the 1st box in Section C of the claim form, or, if retired, claim as a retired physician pursuant to Section B of the claim form. 

Question: What is a Retired Physician?
Answer:
The category covers a Class Member who has retired from the practice of medicine subsequent to January 1, 1990 or who is the legal heir or representative of a deceased Class Member. Retired physicians will receive a pro rata amount of the settlement fund allocated to retired or deceased physicians about 2X the “Base Amount” regardless of the amount they received for treating Humana members.

Question: What is the payment formula for Active Physicians?
Answer:
The Settlement payment will be based upon the gross receipts for the three calendar year period 2003 to 2005 for providing covered services to Humana members.
  • Gross receipts – zero payments to less than $5,000 = Base Amount
  • Gross receipts of at least $5,000 but less than $50,000 = 5X the Base Amount
  • Gross receipts of $50,000 or greater = 10 X the Base Amount. 

Question: Is documentation necessary?
Answer:
No documentation is necessary if you base claim on revenue received from 2003 to 2005.

Alternatively, If the maximum revenue for providing covered services to Humana members was during any other consecutive three year period from January 1, 1996 through December 31, 2005, submit appropriate documentation.

Documentation Required – 1099s or other forms of proof reflecting amounts of payments received from Humana. 

Question: How much is the Base Amount?
Answer:
This will depend upon the number of claims that are timely filed.

Question: How can I get a claim form?
Answer:
Claim forms are available at www.hmosettlements.com. 

Question: What if the physician does not want to be a part of the Settlement?
Answer:
If a physician does not want to be a member of the Class and participate in the Proposed Settlement, the physician BY NO LATER THAN January 18, 2006 must send a signed statement to that effect that includes the name, business address, telephone number and Federal Tax Identification Number to the following:

Humana Physicians Settlement Administrator
P.O. Box 4068
Portland, OR 97208-4068

Question: What are other components of the Humana Settlement?
Answer:
In addition to the monetary component of the settlement, physicians and Humana have agreed to new levels of transparency and communication as well as a renewed commitment concerning business practices through a number of initiatives. In the agreement, Humana has
agreed to, among other things:

  • A definition of medical necessity that ensures that patients are entitled to receive medically necessary care as determined by a physician exercising clinically prudent judgment in accordance with generally accepted standards of medical practice;

  • Use of clinical guidelines that are based on credible scientific evidence published in peer reviewed medical literature (taking into account Physician Specialty Society recommendations, the views of Physicians practicing in the relevant clinical areas, and other relevant factors) when making medical necessity determinations;

  • Conform to proper coding standards including use of AMA CPT®;

  • Provide physicians with access to an independent medical necessity external review process;

  • Establish an independent external review board for resolving disputes with physicians concerning many common billing disputes;

  • Pay for the cost of recommended vaccines and injectibles and for the administration of such vaccines and injectibles;

  • Not automatically reduce the intensity coding of evaluation and management codes billed for covered services;

  • Ensure the payment of valid clean claims within fifteen (15) days for claims electronically submitted and thirty (30) days for claims submitted on paper;

  • Provide complete fee schedules via electronic communication;

  • Establish a compliance dispute resolution mechanism to address disputes regarding Humana’s compliance with the agreement;

  • Limit the use of rental networks;

  • Recognize valid assignment of benefits;

  • Establish a physician advisory committee; and

  • Provide ninety (90) days notice of changes in practices and policies and annual changes to fee schedules.

Managed Care Litigation Settlements to Date:
  • Aetna
  • CIGNA
  • HealthNet
  • Prudential
  • Wellpoint/Anthem
  • Excellus

For more information regarding these settlements see www.hmosettlements.com or www.milbergweiss.com.