Aetna To Announce Settlement With Doctors
Aetna officials on May 22 plan to announce that the company will pay $170 million to settle a class-action lawsuit in which about 700,000 physicians nationwide allege that the health insurer improperly denied and reduced reimbursements, the Chicago Tribune reports (Japsen, Chicago Tribune, 5/22). Aetna Chair Dr. John Rowe said that the company has agreed to pay $100 million to the physicians, $20 million to establish a foundation to improve the quality of health care and $50 million to cover the cost of the legal fees of the plaintiffs (Treaster, New York Times, 5/22). The settlement also will provide an estimated additional $300 million to the physicians through improved automated systems that will eliminate some reimbursement reductions and expedite payments. Under the settlement, Aetna also will adopt a "more physician-friendly" definition of "medical necessity" and will establish an independent "Billing Dispute External Review Board" to resolve disputes with physicians, the Wall Street Journal reports (Martinez, Wall Street Journal, 5/22). Aetna will not admit wrongdoing in the settlement, which will involve about 18 medical societies and associations nationwide, the Hartford Courant reports (Levick, Hartford Courant, 5/22). The settlement is part a larger class-action lawsuit filed by physicians in U.S. District Court in Miami against several large health insurers. The lawsuit alleges that Aetna, United Healthcare, Cigna, Coventry Health Care, WellPoint Health Networks, Humana Health Plan, PacifiCare Health Systems and Anthem Blue Cross Blue Shield delayed or denied reimbursements for health services and rejected claims for medically necessary treatments as part of a racketeering conspiracy (Kaiser Daily Health Policy Report, 5/2). The Miami court must approve the settlement with Aetna (Chicago Tribune, 5/22).
Dentists Sue Health Plans
In a similar lawsuit, the American Dental Association on May 19 filed a suit in a federal district court in Miami alleging that six insurers violated federal racketeering laws by conspiring to delay and reduce payments to dentists, the Miami Herald reports. The suit names Cigna, Cigna Dental Health, Connecticut General Life Insurance, MetLife, Metropolitan Life Insurance and Mutual of Omaha as defendants. The lawsuit claims that the insurers use automated claim-processing systems that "artificially reduce the amount paid" by substituting a code for services with lower reimbursements and by combining multiple treatments to reduce payments (Dorschner, Miami Herald, 5/21). ADA members are seeking an unspecified amount in compensatory and punitive damages, as well as a court order to require insurers to repay "unjustly earned profits" and to stop using automated systems, the Hartford Courant reports. In response to the dental suit, Cigna spokesperson Rick Goulart said the "allegations are without merit." MetLife said it will "vigorously defend" itself against the suit (Levick, Hartford Courant, 5/21). Mutual of Omaha did not comment on the case (Japsen, Chicago Tribune, 5/21).
