CMA Cardiologist Successfully Uses RICO Settlement Dispute Process, Scores Millions of Dollars for Physicians Nationwide
BY SUSAN BASSETT

Patrick S. Coleman, M.D., is a cardiologist in the multi-specialty group Northern California Medical Associates.

Were Your Add On Codes Denied? You Have Until July 14 to Submit a Claim If you, like Dr. Coleman, experienced add-on code denials, you have until July 14 to submit a claim for payment. Aetna’s settlement with the plaintiffs was approved in late 2003. The plan agreed at that time to make changes to payment policies for greater consistency with CPT coding guidelines. However, Aetna did not recognize codes for CAD mammography (CPT codes 76082 and 76083) and myocardial perfusion testing (CPT codes 78478 and 78480) and myocardial perfusion testing – in violation of Sec. 7.20 of the settlement agreement – and claims by physicians were being denied. Some physicians even stopped filing claims because Aetna was not paying them. A number of physicians filed RICO settlement compliance disputes and in 2005 Aetna began paying for these add-on codes. CMA, with the help of physicians like Dr. Coleman, continued to push Aetna to retroactively pay the previously denied claims for add-on codes. As a result of CMA’s advocacy through the compliance dispute resolution process, Aetna agreed in April to retroactively pay claims with add-on codes for CAD mammography and myocardial perfusion testing with dates of service on or after January 1, 2004. Claims for retroactive payment must be filed by July 14. The process for resubmitting previously denied claims is described on Aetna’s provider website. Click on “Add-On Code Claims Payment” in the “Features” section in the lower right corner of the top web page. Physicians should submit new claims following standard billing procedures. More details are available by calling Aetna’s provider service center (888/632-3862 for PPO plans or 800/624-0756 for HMO plans).

In a major victory for physicians, a Santa Rosa cardiologist and his alert staff took a health plan to task for RICO settlement noncompliance and achieved a win for Aetna-contracted physicians nationwide.

Patrick S. Coleman, M.D., is a CMA member and a cardiologist in the multi-specialty group, Northern California Medical Associates, Inc. The medical group’s contracting and compliance manager, Sally DeWald, did not think it was right that Dr. Coleman had experienced multiple denials by Aetna for payment requests for certain add-on codes, even though Aetna had specifically agreed in its settlement of CMA’s RICO lawsuit to pay all add-on codes from the date they became effective under the CPT system.

Ms. DeWald also saw that Aetna’s physician contract contained provisions that violated the settlement terms. They decided to call CMA for assistance.

Aileen Wetzel in CMA’s Center for Economic Services prepared a dispute for nonpayment of myocardial perfusion add-on codes and filed it on behalf of Dr. Coleman with the RICO settlement compliance dispute facilitator, an attorney appointed by CMA’s RICO attorneys to prosecute these disputes without charge to physicians. The facilitator, working with CMA general counsel Catherine Hanson and attorneys from several other state medical societies, resolved Dr. Coleman’s dispute and similar disputes filed by dozens of physicians nationwide. Aetna not only agreed to pay the disputed claims, but also agreed to retroactively pay all physicians whose add-on claims for myocardial perfusion and CAD mammography were not paid. (See sidebar for more details.)

Equally or perhaps even more significant was Dr. Coleman’s challenge of the noncompliant provisions in Aetna’s physician contract. CMA legal counsel provided the dispute facilitator with a detailed contract analysis that documented numerous contract provisions that were not consistent with the RICO settlement agreement. For example, the Aetna contract included a gag clause, even though the settlement prohibits Aetna from restricting physician-patient discussion on treatment or medical decisions. The contract also included a “medical necessity” definition that was inconsistent with the settlement’s definition. Another contract provision improperly prevented physicians from accepting new managed care patients from other plans if they had declined to take additional Aetna patients.

As a result of CMA’s advocacy and Dr. Coleman’s compliance dispute, Aetna agreed to mail contract addendums – addressing these issues and others – to all contracting physicians nationwide and to extend their settlement commitments another full year.

User-Friendly Compliance Dispute Process
The compliance dispute process is simple. CMA, an official signatory medical society on the RICO lawsuits, can assist CMA members and file compliance disputes on their behalf. CMA staff, such as Ms. Wetzel, will file a dispute on behalf of any CMA member physician, ensuring a straightforward process. The two-page dispute form requires basic information including physician name and Tax ID number and a brief description of the compliance dispute.

“I found the advocacy of CMA very helpful,” said Ms. DeWald. “Aileen walked me through the process of filing the dispute and kept me informed of the progress. I would definitely go to CMA for assistance in the future.”

The Importance of the RICO Lawsuit
In an historic action six years ago this month, CMA filed a class action lawsuit against for-profit HMOs in California. Eventually, more than 800,000 physicians and 19 state and county medical associations joined CMA as plaintiffs. The civil racketeering (RICO) lawsuit alleged that the HMOs used fraud and other illegal activities interfere in the physician-patient relationship. The case, which became the largest class-action health care lawsuit in U.S. history, allowed physicians, such as Dr. Coleman, to air profound grievances against an industry that had arrogantly and unfairly exploited them and harmed their patients for more than a decade.

Of the 10 defendants named in the lawsuit, six have settled (including the merged Anthem/WellPoint/Blue Cross), one had its case dismissed, and two are pending.

What the Settlements Mean to Physicians and Patients
In addition to $585 million in monetary damages—about two thirds going directly to physicians—these settlements reflect a binding commitment by these companies to provide an unprecedented level of transparency and fairness in their future payment practices and other business dealings with physicians for a minimum of four years. These prospective commitments have been valued far in excess of the monetary relief—at well over $1 billion.

The plans also funded two physicians' foundations, with assets of over $100 million. These foundations, chaired by CMA CEO, Jack Lewin, M.D., support ongoing study and research to benefit physicians and physician practices nationwide. Money from the Prudential settlement will fund the Physicians’ Advocacy Institute, a national nonprofit organization that fights managed care abuse.

Vigilance by Physicians Supports the Settlements and Prospective Relief
It is essential that the plans abide by the terms of the settlements. While the plans have made great strides, issues continue to rise – and CMA continues to advocate, along with other plaintiffs, on behalf of physicians and patients.

CMA encourages physicians to help ensure these plans keep their promises. If you believe that a health plan is not living up to the terms of its settlement, please contact CMA’s legal department at 415/882-5144 or legalinfo@cmanet.org.

More information on the RICO lawsuits, settlement agreements, compliance dispute resolution, and settlement enforcement are available in CMA's RICO Resource Center.

Related News:

Aetna Settles Modifier 25 RICO Settlement Compliance Dispute
[Posted 05/18/06]

Aetna Agrees to Pay Physicians for Denied Add-On Code Claims for CAD Mammography and Myocardial Perfusion Testing Retroactive to 2004
[Posted 04/13/06]

Aetna Changes Reimbursement Policy, Recognizes Modifiers 25 and 57 in Certain Situations; Physicians Urged to Resubmit Previously Denied Claims
[Posted 04/06/06]

Holding Blue Cross and Other Health Plans Accountable: What the RICO Settlements Mean to You and Your Practice
[Posted 03/30/06]

CMA Encourages Physicians to Donate RICO Settlement Funds to CMA Foundation
[Posted 04/14/05]