“TMA and the other societies who have joined in these lawsuits have found them to be very useful tools to make sure for-profit insurance companies pay doctors fairly — and legally — for the services they provide.”
submit claims dating from 2003 to the present to a general fund or a “prove-up fund.”
Before physicians can file claims in the Aetna settlement, U.S. District Judge Stanley Chesler must approve the settlement. The preliminary approval date was set for late January. Physicians should look for proposed settlement no- tices, claim forms, and instructions in the mail. Physicians will then have 90 days to file a claim, says Edith Kallas, an attorney for the plaintiffs. Joe Whatley, another attorney repre- senting plaintiffs, says it’s impossible to know exactly how many out-of-network physicians in Texas stand to benefit from the settlement with Aetna. “We won’t know until physicians file claims. Aetna has larger market shares in the met- ropolitan areas of Texas. We do know a significant num- ber of Texas physi- cians provided out- of-network proce-
Bohn Allen, MD 30 TEXAS MEDICINE March 2013
dures to patients insured by Aetna,” he said.
TMA and others involved in the Aetna
settlement are working with the compa- ny to address out-of-network policies to help ensure accurate and fair payment to physicians. Donald P. “Rocky” Wilcox, TMA vice
president and general counsel, says the association will continue to hold insur- ance companies accountable for how they do business.
“The private practice of medicine is under siege from all quarters. TMA and the other societies who have joined in these lawsuits have found them to be very useful tools to make sure for-profit insurance companies pay doctors fairly — and legally — for the services they provide. Our members depend on orga- nized medicine to do everything we can to help keep their practices viable,” Mr. Wilcox said.
Filing claims According to Mr. Whatley, physicians can
The general fund will cover indi- vidual physicians with less than $750 in claims or a group practice with less than $1,000 in claims. They will fill out a simplified claim form and are eligible to receive $40 for each year (back to 2003) they provided covered services or supplies as out-of-network physicians or groups. Higher claims submitted to the prove-up fund require documentation, such as copies of balance bills, receipts, and business records. Physicians and groups submitting claims to the prove-up fund have the daunting task of combing through past claims. Tim Schmidt is the chief execu- tive officer of Ohio-based Managed Care Advisory Group (MCAG), a litigation claim recovery and health plan auditing service. Since 2003, MCAG has helped more than 300,000 physicians recoup money in class action settlements. Mr. Schmidt says his company accesses re- cords through practice management sys- tems and clearinghouses to identify the appropriate claims to file. “It would be really hard for physician practices to search records dating back to 2003 and pull out all of the appropri- ate out-of-network claims, submit them correctly with the required documenta- tion, and get their money. It’s a labor- intensive endeavor, and if the informa- tion isn’t submitted correctly, the claim is declared ineligible,” he said. Historically, about 20 percent of eli- gible class members file a claim in class action settlements, Mr. Schmidt says. “The remaining 80 percent of eligible class members throw away the notice of proposed settlement or determine it’s not worth their time,” he said. But he says it’s worth it for physicians
to seek recoupment. In the 2009 class action settlement with United over its use of Ingenix, MCAG collected $114 million out of a total $200 million set aside for physician clients, an average of about 14 cents on the dollar. “Unfortunately, physicians won’t re- ceive a dollar for every dollar they were underpaid in these class action settle- ments. There’s a finite pot of money to
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