CLASS ACTION SETTLEMENTS
Aetna Class Action Settlement Information
MSSNY Position on This Settlement:
As a plaintiff in an action against Aetna the Medical Society of the State of New York supports the settlement. As such the Medical Society of the State of New York urges all physicians to review the material and participate in the settlement.
Major benefits of the settlement include:
- Application of generally accepted medical standards determining medical necessity.
- Agreement on a nationally recognized and physician-approved set of rules governing claims coding and grouping procedures (i.e., no more automatic downcoding of E&M codes, and agreement to use coding rules based on AMA CPT guidelines concerning bundling, modifiers and global periods).
- A joint effort to develop a claims-editing software package that incorporates physician- and industry-accepted claims coding and grouping procedures.
- Increased electronic connectivity and direct, web-enabled access to Aetna systems to verify reimbursement information and track claims.
- Allowing physicians to access a Medical Necessity External Review Process administered by a Medical Necessity Independent Review Organization, to review and challenge Aetna’s medical necessity denials;
- Creation of an independent external review board for resolving disputes with physicians concerning many common billing disputes.
- Payment of $100 million to physicians.
- Payment of $20 million to fund a foundation, to be controlled by the state societies participating in the case, to support initiative to enhance physicians’ ability to focus on the health care of their patients.
Because the Medical Society of the State of New York is part of the settlement, we can represent physician members who have future disagreements with Aetna through a compliance dispute process for violations of the terms of the settlement as well as violations of state law relating to such terms. Those physicians who choose to opt out of the class will not find this compliance dispute process available to them.
Although the payment to physicians is nominal and will be made in accordance with the formula set forth in the agreement, the precedent set by the settlement is extremely valuable in terms of future Aetna behavior and as other class action cases proceed – either to trial or negotiated settlements – and the rules of the claims submission/ processing game are revised.
For more information about the settlement or for another copy of the claim form (some packets apparently were missing this simple form) go to www.milberg.com.
We hope to have a list of frequently asked questions and answers about the settlement on the Medical Society of the State of New York Website this week.
Other state and county associations that have participated in the action, and support the agreement include, in addition to the Medical Society of the State of New York, Alaska, California, Connecticut, Denton County (TX), El Paso County (CO), Florida, Hawaii, Louisiana, Georgia, New Jersey, Nebraska, New Hampshire, North Carolina, Northern Virginia (VA), South Carolina, Tennessee, Texas and Washington.
New Aetna Contract Protects Patients and Physicians
Millions of Americans covered by Aetna Healthcare — and the physicians who care for them — now have new protections against the everyday abuses of managed care health plans, thanks to the nation’s leading state medical societies, including MSSNY. These protections are now backed by the power of a federal judge. The changes incorporate all of the patient- and physician-friendly protections that Aetna agreed to two years ago when it settled a national class-action lawsuit filed by the state medical societies under the Racketeer Influenced and Corrupt Organizations Act (RICO). At the time of the settlement, Aetna valued those protections at more than $300 million. Currently, Aetna provides benefits to 14.4 million Americans.
“This is good news for patients and their physicians,” said MSSNY President Robert A. Scher, MD. “We have battled health plans for years to get them to pay for necessary medical care for our patients. Now we have the contract changes that will require them to do that. And we have a federal court watching it all to make sure they do the right thing.”
The new contracts spell out that patients are entitled to medically necessary care as determined by a physician exercising clinically prudent judgment in accordance with generally accepted standards of medical practice. Health plans may require less-costly alternatives only if they are “at least as likely to produce equivalent therapeutic or diagnostic results.”
The contract changes are another physician and patient benefit stemming from the settlement between Aetna and physicians, which was approved by US District Judge Federico Moreno Nov. 6, 2003. In addition, Aetna has agreed to extend most of the settlement provisions one additional year because of its failure to fully implement the changes before this. Physicians who believe Aetna is not living up to the settlement agreement should contact Julia Stewart, the compliance dispute facilitator, at (877) 760-0157 or firstname.lastname@example.org.
Aetna was the first of 11 for-profit health insurance companies to settle the lawsuits that were consolidated under Judge Moreno in 2001. Since then, CIGNA, Health Net, Prudential, and Wellpoint have also agreed to settle with the state medical societies, who represent the nation’s 700,000 physicians in the case.
To date, the settlements have provided more than $1.3 billion in enhanced protections for patients and returned nearly $350 million to physicians. The RICO case is the largest health care lawsuit in US history.
“For physicians, the new contract means that Aetna will pay them, on time, for the services they provide,” said Dr. Scher. “Now physicians can spend less time worrying about their businesses and more time caring for their patients.”