950,000 MD's Settled
With Aetna & Cigna on ERISA
Rx-1
$$$$$$$$$ERISA
$$$$$$$$$$
Rx-2
US
Supreme
Court Visits ERISAclaim.com
at 11:57:03 AM on Friday, November 21,
2003
Doctors fight Blues over fees - 09/10/04 (The Detroit News)
CMA Rebuts Health Plan
Allegations of Unfair Physician Billing Practices
[Posted
11/11/04]
Click here to download CMA's letter to
DMHC.
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Tort Reform, Fraud
& Healthcare Crisis? |
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New From Center for Justice &
Democracy:
***New Study*** Falling Claims and
Rising Premiums in the Medical Malpractice Insurance Industry
(July 7, 2005)
Appendix
News Release: New Study Leads
Attorneys General to Proclaim “No Excuse” and “A Matter of
Life and Death” (July 7, 2005)
PDF
"Joanne
Doroshow, Executive Director of the Center for Justice &
Democracy, which commissioned the report, stated, “To put it
bluntly, if you look at what the insurance companies say
about why they raise premiums, and then look at the data in
this report, thenumbers just don’t add up. The facts are
very simple: medical malpractice payouts are down yet
insurance companies have significantly increased premiums.
This shows that the
entire campaign to limit liability for doctors over the last
several years by capping compensation to injured patients
has been a fraud, and that based on these data, insurers
must know that it has been a fraud.”
Study Backgrounder (July 7, 2005)
PDF
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ERISAclaim.com - A $1.0 Trillion Nuclear
Solution to U.S. Health-care Crisis & $44 Trillion Budget
Deficits |
|
Aetna +
CIGNA
Settlement
Demystified
© 2004 Jin Zhou, ERISAclaim.com
Settlements =
ERISA + 3
E. B.
Settlements =
ERISA + 3
E. B.
(Click
on each hyperlinks for details)
"Aetna
and CIGNA Settlement Secrets"(www.aetna.com)
Aetna ERISA "Talking
Points" (www.aetna.com) |
-
ERISA stands for
Employee Retirement Income Security Act
-
E. B. = External Boards (of
Reviews) (§7.10-7.11):
1) Medical Necessity, 2)
Billing & Coding and
3)
Policy
Coverage
-
Settlements
Only for
MCO/Provider Contract Disputes
-
Settlements
Not for
Patient Coverage/ERISA Disputes, (§7.10-7.11)
-
Patient
Disputes =
ERISA/Coverage/Medical
Necessity/Bundling
& Down Coding
-
Provider
Disputes =
PPO Discount/HMO Capitation/Provider Relationship
(DOL FAQ A8)
-
Patient
Disputes
≠
Provider
Disputes, (DOL FAQ A8); Provider/MCO Contract
(PPO/HMO) Disputes are
not Triggered
until Patient
ERISA Disputes With the
ERISA Plan Are
100% Resolved or Moot (DOL FAQ C12)
(PASCACK VALLEY HOSPITAL, INC.
v LOCAL 464A UFCW WELFARE REIMBURSEMENT PLAN
(3rd Cir. 11/01/2004),
Northeast Hosp. Authority v. Aetna Health Inc.,
(October
17, 2007)
-
External
Reviews (3 E. B.)
Are Not
Available until
Internal Reviews (ERISA) Completed,
(GAO)
-
ERISA =
Federal Law Mandate;
External
Reviews
= State Law Mandate, (GAO)
-
No
ERISA Compliance =
No Rights for Any One
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Title 29 U.S.C. § 1141 states:
"It shall be unlawful for any
person through the use of fraud, force, violence, or threat of
the use of force or violence, to restrain, coerce, intimidate,
or attempt to restrain, coerce, or intimidate any participant or
beneficiary for the purpose of interfering with or preventing
the exercise of any right to which he is or may become entitled
under the plan, this title, section 3001, or the Welfare and
Pension Plans Disclosure Act. Any person who willfully violates
this section shall be fined $10,000 or imprisoned for not more
than one year, or both. The amount of fine is governed by 18
U.S.C. § 3571. The U.S. Sentencing Guidelines address 29 U.S.C.
§ 1141 under the guidelines for "Fraud and Deceit" (U.S.S.G. §
2F1.1) or for "Extortion by Force or Threat of Injury or Serious
Damage (U.S.S.G. § 2B3.2)......"
"For example, Section 1141
would reach the use of deception directed
at misleading a welfare plan beneficiary as to the amount of
health benefits owed to the beneficiary under the terms of the
plan or at misleading a pension plan participant as to
the amount of retirement benefits to which he would become
entitled under the plan upon his retirement."
ERISA in the United States Code
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Breaking News
Are All
Consultants Corrupt? (Fast Company)
Did you know that
950,000
physicians nationwide have settled and agreed with Aetna and CIGNA in
their class-action lawsuit that 950,000 physicians must complete two
levels of ERISA appeals as health plans internal appeals for both ERISA
claims and non-ERISA claims before they can access the state protections
through state external review laws?
Did you know that 40 states
require the completion of
ERISA appeals by physicians or patients as
health plan internal appeals before anyone can claim state law
protections through state external review laws?
Ask your state association for more details on
how to complete ERISA appeals for your denied and delayed medical
claims.
A.
AETNA SETTLEMENT AGREEMENT (pdf, 97 pages), dated as of May 21, 2003 by and among AETNA INC., THE
REPRESENTATIVE PLAINTIFFS, THE SIGNATORY MEDICAL SOCIETIES AND CLASS
COUNSEL
"7.10. New Dispute Resolution Process for
Physician Billing Disputes.
a."......Nothing contained in this § 7.10 is intended, or shall be
construed, to supercede, alter or limit the rights or remedies otherwise
available to any Person under
§ 502(a) of ERISA or to supercede in any
respect the claims procedures of § 503 of ERISA."
[page 25]
7.11. Medical Necessity External
Review Process.
"(c) Notwithstanding
the provisions of § 7.11(a), Physicians
may not seek review of any claim for which the Plan Member (or his or
her representative) has filed suit under § 502(a) of ERISA. In
that event, or if such a suit is subsequently initiated, the Plan
Member’s lawsuit shall go forward and the
Physician’s claims shall be dismissed and may not be brought by or on
behalf of the Physician in any forum; provided that such
dismissal shall be without prejudice to any Physician seeking to
establish that the rights sought to be vindicated in such lawsuit belong
to such Physician and not to such Plan Member.
(d)
Nothing contained in this § 7.11 is intended, or shall be construed, to
supercede, alter or limit the rights or remedies otherwise available to
any Person under § 502(a) of ERISA or to supersede in any respect the
claims procedures under § 503 of ERISA.
e. Company shall maintain an internal
appeals process for medical necessity denials and shall disclose
such process on the Public Website. Company shall adjudicate all such
appeals of medical necessity denials on the timeframes that are
applicable to Plans
subject to ERISA, regardless of whether such
Plans are actually subject to ERISA......." [page 30]
Aetna Settlement Claim Form
(pdf)
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Aetna Reports First Quarter Results
HARTFORD, Conn.--(BUSINESS WIRE)--April 29, 2004--
"-- First-quarter operating earnings, excluding
favorable reserve development, of $1.75 per share, compared with
Thompson/First Call mean of $1.72, a 31 percent increase over
prior-year quarter
-- First quarter net income of $2.28 per share
-- Medical membership increase of 342,000 from
year-end 2003"
"We also announced several new initiatives to
reduce complexity for and improve communications with
physicians, including a new information resource, a billing
dispute mechanism, and dedicated service centers. And the
National Advisory Committee of Practicing Physicians, recently
formed as a direct result of our 'new era of cooperation'
agreement with physicians, held its first meeting."
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B.
CIGNA SETTLEMENT
(pdf, 150 pages )
(doc)
"7.10
Dispute Resolution Process for Physician Billing Disputes.
a. CIGNA
HealthCare shall implement an independent, external billing dispute
review process (the “Billing Dispute External Review Process”) for
resolving disputes with Class Members concerning the application of
CIGNA HealthCare’s coding and payment rules and methodologies to (i)
patient specific factual situations, including without limitation the
appropriate payment amount when two or more CPT® Codes are billed
together, or whether the Class Member’s use of modifiers is appropriate,
or (ii) any Retained Claims, so long as such Retained Claims are
submitted by the Physician to the Billing Dispute External Review
Process prior to the later to occur of either ninety (90) days after
Final Approval or thirty (30) days after
exhaustion of CIGNA HealthCare’s internal appeals process. Each
such matter shall be a “Billing Dispute.” The Reviewer (as defined
below) shall not have jurisdiction over any disputes that are not
patient specific application of Claim Coding and Bundling Edits,
including without limitation those disputes that fall within the scope
of the Medical Necessity External Review Process set forth in Section
7.11 of this Agreement, disputes about the submission of Clinical
Information that fall within the scope of Section 7.12, Compliance
Disputes and disputes concerning the scope of Covered Services.
Nothing contained in this Section 7.10 is
intended, or shall be construed, to supersede, alter or limit the rights
or remedies otherwise available to any Person under § 502(a) of ERISA or
to supersede in any respect the claims procedures of § 503 of ERISA.
"(3)
Time Limits for Completing Internal Appeals.
All internal
appeals shall be completed within the time limits required by
regulations issued by the Department of Labor, even those
internal appeals for which ERISA is not applicable.
[page 50]
(3) Notwithstanding the provisions of this Section
7.11, Class Members may not seek review of any claim for which the CIGNA
HealthCare Member (or his or her representative) has filed suit under §
502(a) of ERISA or other suit for the denial of health care services or
supplies on Medical Necessity grounds. In that event, or if such a suit
is subsequently initiated, the CIGNA HealthCare Member’s lawsuit shall
go forward and the Class Member’s claims shall be dismissed and may not
be brought by or on behalf of the Class Member in any forum; provided
that such dismissal shall be without prejudice to any Class Member
seeking to establish that the rights sought to be vindicated in such
lawsuit belong to such Class Member and not to such CIGNA HealthCare
Member. [page 52]
"(4) Nothing contained in
this Section 7.11 is intended, or shall be
construed, to supersede, alter or limit the rights or remedies otherwise
available to any Person under § 502(a) of ERISA or to supersede in any
respect the claims procedures under § 503 of ERISA."
[page 53]
Anti-balance Billing Instruction
to Non-participating Physicians (page 80-81)
"p. Participating Physician Status Dependent Upon Existence of
Contracts; Limitations on Obligations of Non-Participating Physician.
CIGNA HealthCare agrees that it will treat a Class Member as a
Participating Physician only in those circumstances in which the Class
Member is a party to a written contract with CIGNA HealthCare or with an
intermediary with which CIGNA HealthCare has a written contract. CIGNA
HealthCare further agrees that at least through the Termination Date, it
will not rent its networks to any other managed care company or health
insurer for the purpose of providing health care services or supplies to
any person who is not a CIGNA HealthCare Member; provided that nothing
in this sentence shall prevent CIGNA HealthCare from making its networks
available among the various current and future Subsidiaries of CIGNA
Corporation; and provided, further, that nothing in this sentence shall
be held to apply to a situation in which a CIGNA HealthCare customer
elects to make payments on claims in respect to provisions of health
care services or supplies to a CIGNA HealthCare Member through a third
party administrator or where CIGNA Behavioral Health provides mental
health services for another health insurance company or other entity. No
affirmative obligation that this Section 7 imposes on a Participating
Physician shall apply to Non-Participating Physicians unless and until,
and then only to the extent that, with regard to each individual claim,
such Non-Participating Physician submits or transmits to CIGNA
HealthCare a claim for payment which designates therein that the
Non-Participating Physician has accepted an Assignment of the CIGNA
HealthCare Member’s benefits as payment for that individual claim.
q. Effect of Assignment of Benefits.
The existence of an Assignment of Benefits authorization, whether or not
submitted by the Non-Participating Physician to CIGNA HealthCare,
does not constitute in and of itself full or
partial payment of the Non-Participating Physician’s fee (unless so
agreed between the Non-Participating Physician and the CIGNA HealthCare
Member), does not create an implied contract between the
Non-Participating Physician and CIGNA HealthCare, and does not limit the
Non-Participating Physician’s fee to any fee schedule. The
Non-Participating Physician retains the right to elect either to collect
the Non-Participating Physician’s full fee from the CIGNA HealthCare
Member or collect partial payment from CIGNA HealthCare and the balance
from the CIGNA HealthCare Member (“balance bill”)."
C.
Both Aetna and CIGNA have agreed to
settle the class-action lawsuits by 950,000 physicians and agreed to
process appeals in accordance with
ERISA claim regulations for both ERISA claims
and
non-ERISA claims, and to establish external review
boards for
Billing and Coding Disputes,
Medical Necessity Disputes and Policy Coverage Disputes, in
compliance with state external review laws, however external reviews
will not be available until internal appeals/ERISA appeals are
completely exhausted.
D.
950,000 physicians agreed to complete
ERISA appeals to Aetna and CIGNA with 100% of the claims
for both ERISA claims and
non-ERISA claims, instead of
80% of
claims under
ERISA
plans, and
to complete
ERISA appeals to Aetna and CIGNA
in all 50 states instead of
40 states where state
law requires exhaustion of health internal appeals process before
seeking for external review under state laws for
Billing and Coding Disputes,
Medical Necessity Disputes and Policy Coverage Disputes.
E.
All other 8 major insurance companies named in class-action lawsuit have
refused to settle,
even if federal court would rule for physicians, the Aetna and CIGNA
settlements will be as good as it could get from the rest of insurers
and MCO's as evidenced in Aetna and CIGNA settlements with physicians.
F.
Unless physicians understand and
complete ERISA internal appeals, all of
those
"a love fest" and
"victories" from class-action settlements would mean a fantasy of
"a love fest" to any
physicians.
"Forty
states required individuals to first exhaust their health policy’s
internal appeals and grievance process before seeking external review."
According to United States General Accounting
Office (GAO) Report to Congressional Requester, dated September 2003,
Page 46.
The health policy’s internal appeals and grievance process =
ERISA appeals for
80% of the
health claims.
Judge approves $540 million Cigna settlement with doctors
950,000
Physicians Agreed to Do ERISA Appeals
in
Settlement of Physician Class-Action Lawsuits
Judge Approves Aetna Settlement (CNN, 10/25/03)
"Aetna
and CIGNA Settlement Secrets"
"Talking
Points"
What You
Should Know about Filing Your Health Benefits Claim
Court Approves
Settlement between Cigna and 700,000 Physicians (HMOcrisis.com)
AMA
SUPPORTS CIGNA SETTLEMENT WITH NATION’S PHYSICIANS
