To help physicians maximize their recovery under the CIGNA RICO settlement, CMA has reached an agreement with a company to provide claims analysis and filing assistance to CMA members at a significant discount. The company—the Managed Care Advisory Group (MCAG)—uses computer analysis to identify all eligible claims and streamline the claims submission process for physicians.

Virtually all physicians are entitled to damages under the class-action settlement regardless of whether they treated CIGNA patients or not. The class includes all physicians who provided covered services between August 4, 1990 and September 5, 2003 to any patient covered by any of the defendants in this case—CIGNA, Aetna, Anthem, Coventry, HealthNet, Humana, PacifiCare, Prudential, United Healthcare, and WellPoint. Although CIGNA and Aetna have settled, the lawsuit continues against the other health plan defendants and the trial is scheduled to begin March 14.

Your Settlement Options
To receive a share of the settlement monies, physicians must choose between two funds, described below. CMA urges physicians not to file until they have carefully considered all their options. Your election is irrevocable.

CATEGORY A FUND: Physicians who choose to file under this fund will share in a $30 million, national, no-questions-asked pool of funds. The $30 million will be distributed on a pro-rata basis shortly after the claim period ends on Feb. 18.

To claim your share, just return the proof of claim form between Aug. 23, 2004, and Feb. 18, 2005. There is no need to submit supporting documentation.

Please carefully evaluate your particular situation before you decide to participate in the Category A fund. The first claim form you submit will determine your status for reimbursement. Once you submit a Category A claim form, you may not change your mind and elect to seek reimbursement for the specific claims described below. This restriction also applies to a group practice where physicians bill under the same tax identification number. If you are part of a group practice, make certain that all physicians understand and agree with group’s decision. Submitting a Category A claim form under the group’s tax identification number will prevent any physician who uses that number from seeking reimbursement from the uncapped Claim Distribution fund, described below.

CLAIM DISTRIBUTION FUND: Physicians who are able to document that their claims were improperly downcoded, bundled, or denied based on medical necessity, are eligible to receive payment from the Claim Distribution fund. This uncapped fund has been set at a minimum of $40 million. and will be replenished by CIGNA as often as necessary to pay all valid proof-of-claims.

Physicians who have treated CIGNA patients may be entitled to substantial damage awards from the Claim Distribution fund. CMA is encouraging as many physicians as possible to seek compensation from this unlimited fund. There are three categories of claims eligible for compensation from this fund:

Category One Claims: Category One is a list of 1,200 specific coding pairs that CIGNA bundled—but shouldn’t have. The settlement requires CIGNA to repay physicians for every unpaid pair they can document. Payments for category one codes range from $3 to more than $650. Click here to view a code pair list with the exact amounts and the applicable dates of service for each pair. (Category One claim forms are available online in the RICO Resource Center.)

Category Two Claims: Category Two covers other improper coding and bundling edits, including those involving evaluation and management services and associated procedures or codes. The settlement requires CIGNA to “use its best efforts” to provide each physician with a “facilitation list” of codes and claims that might be eligible for Category Two. To request a facilitation list, call the settlement administrator at 877/683-9363. (Category Two claim forms are available online in the RICO Resource Center.)

Medical Necessity Claims: Under the settlement, physician may ask CIGNA to take a second look at claims they believe were improperly denied as not medically necessary or as experimental or investigational. If CIGNA again denies the claims, they will be forwarded to an independent review entity for final determination. (Medical Necessity claim forms are available online in the RICO Resource Center.)

Click here for more information on the different compensation categories available under the CIGNA settlement.

How Can MCAG Help?
Before you decide to just take your share of the Category A pool and be done with it, consider this: MCAG analyzed past CIGNA claims for a 100-radiologist group in California found that the group will receive a settlement payment of more than $1 million.

MCAG’s easy-to-use process will help physicians review their CIGNA claims, determine which payment fund will maximize their settlement payment, and submit the necessary claim forms and supporting documentation. MCAG’s automated online process allows physicians to quickly and securely upload patient files. Physician may also choose to submit patient data in other file formats, including tapes, CDs, and paper.

MCAG receives a modest filing fee of $12-$50 plus a contingency fee based on the final settlement payment. CMA members receive a 17 percent discount. Physicians who are members of both CMA and AMA get a 30 percent discount. This is a significant member benefit, because many physicians will be eligible for thousands of dollars in damages from CIGNA.

Physicians can sign up for MCAG’s services at http://www.mcaginc.com.

For more information on the RICO lawsuit, visit the RICO Resource Center.

Contact: CMA’s legal information line, 415/882-5144 or legalinfo@cmanet.org.