For More Information Federal Appeals Court Affirms Aetna RICO Settlement [Posted 09/30/04] Federal Appeals Court Upholds Class Certification of CMA's RICO Lawsuit [Posted 09/02/04] For more information, visit CMA's RICO Resource Center.

Are your claims being underpaid? Underpayment is such a common problem that CMA filed a class action RICO lawsuit against 10 of the nation’s largest for-profit health plans, accusing them of systematically defrauding physicians by engaging in unfair payment practices, including:

• Using the wrong fee schedule. (With most physicians maintaining multiple PPO, IPA, and other network agreements, payment rules can be difficult to track. Some plans will pay you from the lowest fee schedule, even if the service was provided under a different contract.)
• Downcoding E&M service codes.
• Bundling codes using payment rules that are not consistent with CPT guidelines and conventions.
• Omitting service line items due to data entry or other system errors.

CMA’s RICO suit has already resulted in multi-million-dollar settlements with Aetna and CIGNA, two of the HMO defendants. Both Aetna and CIGNA have agreed to make significant changes to the way they do business with physicians. But other plans are still fighting us and many continue to regularly and sometimes intentionally underpay physician claims.

For most physician practices, it is virtually impossible to identify underpaid claims. Even with the best billing and collections software, you would have to load all the fee schedules and payment rules for each payer and for each of the many different plans offered by those payers.

Even when you identify an underpaid claim, filing an appeal is time-consuming and costly. Payment reconciliation can be a money-losing proposition.

Infinedi, a CMA partner, recently launched Q-Compare, a real-time online service that will compare the amount paid against the appropriate fee schedule, notify you if a claim is underpaid, and automatically generate appeal letters as necessary. Although many of you may recognize Infinedi as CMA’s HIPAA-compliant clearinghouse partner, Q-Compare works with most practice management software, regardless of the clearinghouse you use.

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