Physicians score victory in class-action compliance settlement

Aetna and medical societies involved in the original case against HMOs have resolved a dispute related to the insurer's denial of specific claims.

By Mike Norbut, AMNews staff. June 5, 2006.

Physicians involved in class-action settlements with the health insurance industry have used them successfully to resolve a dispute involving Aetna's denial of a specific coding modifier.

In an agreement worth at least $6.3 million to doctors, Aetna agreed to pay previously rejected physician claims for reimbursement when the CPT modifier 25 was added to an evaluation and management service.

Any physician who did not opt out of the original class-action case and had this type of claim denied dating back, in some cases, to the effective date of the settlement -- May 21, 2003 -- should see money from this agreement, officials said.

The company also has agreed to fix its claims-payment system to pay these codes correctly going forward.

"Since the cases were settled, the medical societies have worked together to enforce compliance," said Carol Scheele, associate general counsel for the North Carolina Medical Society, one of the physician organizations involved in the dispute resolution. "Part of the [original settlement] agreement is that they pay modifiers. Not paying these code combinations is a major, major violation of this agreement."

As health plans started to settle class-action cases against them over the last few years, there was concern among physicians that getting insurers to comply with the terms of the agreements would be a difficult task.

There already have been several claim disputes between physicians and insurance companies, and more are expected as other settlements are made official.