Anesthesiologists Should Claim Their Share of $120 Million Aetna UCR Litigation Settlement
Anesthesiologists and other physicians who provided out-of-network services to Aetna patients for part or all of the period from 2003 to 2013 may be eligible for a share of the $120 million settlement agreement in the Aetna usual-and-customary (UCR) class action lawsuit.
This litigation arose out of the use by Aetna and other health plans of the Ingenix claims database and certain other reimbursement practices with respect to out-of-network services and supplies, allegedly resulting in artificially reduced payments. The settlement agreement received preliminary approval from the federal district court in Newark, New Jersey in August 2013. A final hearing to consider the “fairness, reasonableness and adequacy” of the agreement is scheduled for March 18, 2014.
Physicians have three choices with respect to the Aetna UCR litigation:
- File a claim and share in the ultimate distribution of the Net Settlement Fund; or
- Request exclusion from the Class by the deadline of February 26, 2014, and not participate in the distribution of the settlement, but retain the right to sue Aetna independently, or
- Do nothing at all, and not share in the distribution of the settlement, but nevertheless be bound by any judgment or Court order.
Individual physicians can participate in the settlement by filing a claim with the settlement administrator. Many physicians have received a copy of the Notice of Proposed Settlement of Class Action and Final Settlement Hearing directly from the administrator. If you do not have a copy, but would like to file a claim, you may download the Notice from this Alert or from http://www.berdonclaims.com, choose the appropriate option, and submit the form and the requisite documentation to the administrator (Aetna UCR Litigation, c/o Berdon Claims Administration LLC, P.O. Box 15000, Jericho, NY 11853-0001; Fax: 516-393-0031; Email: aetna@berdonclaimsllc.com).
The amount that each physician ultimately receives will depend on whether he or she selects the simplified “Option 1” or the standard “Option 2,” which requires more extensive documentation. The amount available under Option 1 will be up to $40 for each year between 2003 and 2013 in which the physician was paid by Aetna as an out-of-network provider. Physicians who claim under Option 2 will be eligible for shares of as much as $5,000 or more. The final amounts payable under both options will depend on how many providers and Aetna plan subscribers ultimately sign up to participate in the settlement. As the number of parties sharing in the $120 million (less expenses) increases, the amount available for each claimant will decrease.
The deadline for filing claims is March 28, 2014.
To file under Option 1, physicians should complete the Provider Claim Form that begins on page 11 of the Notice requesting Option 1. This requires the claimant to provide his or her name and address and Tax Identification Number, to indicate whether the claim is being submitted as an individual provider or for a group, and to circle the years during the period from June 3, 2003 to August 30, 2013 that the claimant provided and billed for covered services or supplies to an Aetna plan member, “where those services resulted in a Partially Allowed Claim (i.e., the Allowed Amount was less than the Billed Charge but more than $0).”
To file under Option 2, physicians must (a) have received an assignment from an Aetna plan member, (b) have balance-billed the Aetna plan member and (c) not have received full payment of the bill. The aggregate amount of balance bills constituting the claim against the Provider Settlement Fund must exceed $750 for individual out-of-network providers and $1,000 for out-of-network provider groups. As shown in the Section B chart on the settlement administrator’s website, for each Partially Allowed Claim the provider must give the following information:
- CPT or HCPCS code, or other description of the covered service or supply
- Date of service
- Name of Aetna plan member originally billed
- Original billed amount
- Allowed amount
- Attestation of assignment received from plan member
- Any payment amounts received for the Partially Allowed Claim and the source of the payment
- Amount of balance bill sent to the member
- Whether any payment of balance bill was received or promised
Some of this information may already be in the settlement administrator’s possession, as the firm has received certain claims information from Aetna. Physicians may request such information from the administrator and use it to complete their claim submissions, using the Claims Information Request Authorization Form on page 15 of the Notice. Should this information not be available from the administrator, it will be necessary to provide the missing data from other sources.
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Physicians who file the claim form to participate in the distribution of the funds should not expect to see a check in the immediate future. As stated in the administrator’s Frequently Asked Questions, “Since Aetna insures millions of people, we expect to receive a very large number of claims, so this process may take a substantial amount of time. All claims are first reviewed and evaluated and then claimants with deficient claims are given a chance to cure them. After the Court approves the distribution, payments will be made to eligible claimants based on the Settlement Administrator’s findings. Please be patient.”
In our opinion, the benefit of filing a claim is apt to outweigh the cost for most eligible physicians, at least for Option 1, which requires no documentation beyond the claim form. If, hypothetically, there are 12 physicians in a group practice who provided services to out-of-network Aetna patients and who were paid less than billed charges, for an average of eight years between 2003 and 2013, the group could ultimately receive $3,840 ($40 x 12 x 8) for a rather small effort. Groups that can document Option 2 claims stand to gain more. ABC will determine and submit the appropriate choice for all of our clients who may be members of the class of providers covered by the settlement agreement. We encourage all physicians reading this Alert to do likewise.