The latest development in the healthcare class-action settlement will affect approximately 900,000 physicians (and some major state medical societies) who may be eligible to receive compensation from the settlement – as long as they file a claim. The case has been called “historic” by those representing both physicians and insurance companies.
The lawsuit, known as Managed Care Litigation, was originally filed in 2000 on behalf of physicians against for-profit health insurance companies. The court case combined several cases filed around the country. The allegations against these health insurance companies claimed that they systematically denied claims and either delayed or reduced payment to physicians who delivered services to covered patients. The suit was filed against many top insurance companies: Aetna, BlueCross BlueShield Health Plans, Cigna, Health Net, Humana, United Healthcare, and WellPoint Anthem. (See settlement amounts for individual insurance companies in Table 1) To be considered for any settlement monies, individual clinicians need to file a claim form. Download claim forms for individual carriers at www.hmosettlements.com.
Some insurance carriers made additional commitments outside of the monetary settlement, such as new levels of transparency and improved communication with physicians. There was also a commitment to enhance better business practice for audits and overpayment recoveries. According to the Managed Care Litigation Settlement Summary, insurance carriers are to adhere to the following guidelines:
- Defining medical necessity that ensures patients are entitled to receive care as determined by the physician exercising judgment in accordance with general accepted standards of medical practice;
- Using clinical guidelines based on credible scientific evidence published in peer-reviewed medical literature (including physician specialty society recommendations) when determining medical necessity;
- Not automatically reducing evaluation and management codes billed for covered services;
- Providing 90 days’ notice of changes to practice policies and fee schedules; and
- Providing access to an independent medical necessity external review process.
See settlement details and a summary of the commitments made by insurance at www.hmosettlements.com or www.rheumatology.org/practice. For more information, contact Antanya Chung, CPC, in the ACR practice advocacy department at (404) 633-3777 or [email protected].
