HMO Settlements

AETNA FLORIDA Emergency Services and Care Settlement:

Who is eligible for this settlement:

Any and All physicians, physician groups, or physician organizations who provided emergency services and care in Florida to any HMO plan members and who were paid by Aetna for those services outside of any contract or agreement during the class period (June 3rd, 2003 to December 15th, 2008).

What is this settlement about:

The Class alleged that Aetna violated Sections 641.513 Florida Statutes, a statue governing “usual and customary” payments by Florida HMOs to physicians who rendered Emergency Services and Care to HMO plan members.

For each claim you properly re-submit through the settlement process, you should receive the difference between 125% of Medicare Rates (Aetna’s historical allowance) and 238% of Medicare Rates (the agreed upon settlement amount).

How do you file:

You can choose to file on your own, or you can use MCAG to file on your behalf. To file on your own, you must submit a claim form to the settlement administrator by May 4th, 2009. At this point, Aetna will use its “Best effort” to determine how much they underpaid your practice for the time frame of June 2nd, 2007 through December 15th, 2008, and send you payment.

If you choose to use MCAG to assist you in filing, you must request a MCAG client services contract and submit it to MCAG no later than April 27th, 2009. At this point, an MCAG representative will contact you to gather the information necessary to file a claim. MCAG will use the billing information (Provided by you, or your billing company) to audit Aetna’s “Best Effort” calculation, and perform the necessary appeals to ensure that you receive what is rightfully yours.

MCAG will also use the billing data to determine if you are eligible to submit claims that were underpaid before June 2nd, 2007. To do so, the settlement requires the class member to submit supporting documentation, which MCAG will recreate from the billing data when possible, and work with your practice to retrieve other documents if necessary.

HMO Settlement Filing

The HMO MDL lawsuit is one of the largest class action lawsuits ever brought to Federal Courts in this country. The lawsuit named ten (10) of the largest managed care payers in the country and alleged payment practices including the down-coding and unbundling of claims. The lawsuit sought civil damages (financial awards and changes in business practices) and RICO damages (criminal damages for triple the financial relief) from Aetna, CIGNA, Prudential, HealthNet, Humana, Coventry, PacifiCare, United HealthCare, Anthem BCBS and Wellpoint.

To date, Aetna, CIGNA, Prudential, HealthNet, Humana, Anthem/Wellpoint and BCBS have settled and all provided both retrospective (refunds of about $400 million to date) and prospective (changes in business practices) relief.

Maximized Returns

Automatic Collection/Effortless Returns: MCAG makes sure that clients do not miss deadlines or fail to collect on refunds that they are due under these Settlements.

MCAG will maximize the return that the client is entitled to collect. Once the physician/practice enrolls with MCAG (one time only) MCAG will automatically file all returns/claims for physicians for the remainder of all settlements at they come due. MCAG files the claims, collects the money and returns the money to the practice after they extract their percentage fee. MCAG only collects a fee as a percentage of what they actually collect for the practice.

Prospective Relief

While the MDL settlement payouts have been substantial, the prospective changes required by the Court will have a far greater impact on future revenues. We are aware of payers who have not been fully compliant with the changes in business practices as mandated by the Southern District Federal Court. This continues to be a big issue for physicians and hospitals alike.

One way to ensure the rights of your settlement is to make sure that your contracts include new language consistent with the mandated changes. In Partnership with MedRecover, MCAG maintains first-hand knowledge of the new rights and remedies that physicians gained in the HMO MDL litigation. The class action lawsuits created a new set of rules for payers. These changes include specific payment and contracting rules that are not well-understood by most physicians and hospitals. Most of these rules will expire over the next three to five years. It is important for providers to understand what they have gained and to maintain the appropriate contract language throughout the settlement period and beyond. These new rules could improve net revenues by as much as 5% each year over the next several years.