CLASS ACTION SETTLEMENTS
For the most up to date information go www.hmosettlements.com
CIGNA RETROSPECTIVE CLAIMS
PLEASE RETAIN BILLING AND MEDICAL RECORDS
If you are, or have been, a physician or physician group who practiced in the United States between August 4, 1990 and September 5, 2003, and you have not filed a timely opt out notice, you are a member of the Class in a settlement with CIGNA Corporation in the class action lawsuit known as In re Managed Care Litigation.
The components of the settlement include:
- Prospective Relief-Changes in disclosure and business practices (valued in excess of $400 million)
- Retrospective Relief
While MSSNY believes that the main value of the Settlement Agreement is the Prospective Relief, including the promises CIGNA has made to change its business practices going forward, the Settlement does provide a minimum of $70 million in damages to physician class members.
Your Category A Share
to the MES Foundation
The Medical Educational and Scientific Foundation of New York, Inc. (MES Foundation) is the charitable medical foundation founded and sponsored by MSSNY. It is a tax exempt 501(c)(3) organization approved by the IRS. The MES Foundation is organized and operated exclusively for educational, scientific and charitable purposes in the field of medicine.
Pursuant to the terms of the CIGNA settlement, you may contribute your Category A share to the MES Foundation. MSSNY hopes you will strongly consider supporting the MES Foundation. If you decide to contribute your Category A share to the MES Foundation, Section II of the Category A claim form must be filled out.
The Category A claim form must be completed and mailed to the Settlement Administrator at the following address:
CIGNA Physician Settlement
P.O. Box 3170
Portland, OR 97208-3170
In order to preserve the physician’s ability to submit claims for retrospective monetary payments, MSSNY strongly urges physicians and medical groups to retain billing and medical records relating to medical services provided to CIGNA members – dating back to August 4, 1990, the beginning of the class period.
Question: When can I submit requests for payment?
Answer: The Settlement Administrator will send notices to class members that will include detailed instructions regarding how claims can be submitted. Recently, an appeal was filed to the CIGNA Settlement. This will likely delay the issuance of these notices by the Settlement Administrator. The notices will likely not be issued until the appeal (or appeals) is resolved.
Question: What kinds of requests for payment can be made?
Answer: Under the Settlement, class members may choose between two types of compensation.
- Category A Settlement Fund
- Claim Distribution Fund
A class member may seek compensation from EITHER the Category A Settlement Fund or the Claim Distribution Fund, but not both.
1. Category A Settlement Fund
CIGNA will pay $30 million into this fund. This category is for class members who choose not to submit documentation to obtain payment. Each member desiring to file a Category A claim may either receive the payment from the Category A Settlement Fund or direct that such amount be contributed to the medical foundation established under the settlement or to a medical foundation established by a state medical society such as the Medical, Educational and Scientific Foundation of New York, Inc. ("MES Foundation") which is established by MSSNY. The amount payable to any one individual under Category A depends upon the total number of class members who elect to claim under Category A. Any class member filing a Category A Claim will not be eligible to seek Category One, Category Two or Medical Necessity Denial Compensation.
The Claim Distribution Fund
If a physician chooses not to submit a claim under Category A, the physician may instead seek compensation under the Claim Distribution Fund for certain claims that were denied or for which payments were reduced. The Claim Distribution Fund has three categories:
a. category One Compensation
b. Category Two Compensation
c. Medical Necessity Denial Compensation
- Category One Compensation
- Category One Compensation applies to denials of or reductions in payments resulting from certain Claim Coding and Bundling Edits. Denials of or reductions in payment for Category One codes resulting from the application of other payment and benefit limitations (e.g. coordination of benefits rules, violations of pre-authorization requirements, violation of referral requirements) are not eligible for Category One Compensation.
- The parties have negotiated a list of specific code combinations which qualify for Category One Compensation.
- Category 1 Compensation List
- Category 1 Codes DeCoded can help physicians decipher the Category One Compensation List. A special thanks to the Tennessee Medical Association who was responsible for preparing the document and allowing MSSNY to post it here.
- Category One Proof of Claim Form
Acceptable Documentation for Category One Compensation includes:
- A copy of the relevant CIGNA HealthCare Remittance Form showing the Category One Codes that were submitted for payment under the circumstances and within the date of service limitations;
- A copy of the HCFA 1500 form (now known as the CMS 1500) or other claim form showing the Category One Codes that were originally submitted to CIGNA HealthCare for payment under the circumstances and within the date of service limitations;
- If the physician certifies that the CIGNA HealthCare Remittance Form and the HCFA 1500 or other claim form cannot be located and are not available, the physician may submit copies of internal accounting records (such as printout of accounts receivable records or paid account records) with the Proof of Claim Form.
- Category Two Compensation
Category Two Compensation applies to denials of or reductions in payment resulting from the application of Claim Coding and Bundling Edits other than those for which Category One Compensation applies. Category Two compensation is available for any denials of or reductions in payment of Category One codes that occurred outside the circumstances and/or date of service limitations identified in the Category One Code list.
If CIGNA denied the Proof of Claims it will automatically be sent to an external reviewer for a final determination.
For Category Two Compensation the documentation must include:
Exceptions to Clinical Information Requirement
- Documentation (i) that the physician was denied payment, in whole or in part; (ii) that the physician received reduced payment, including payment for a different billing code than the one(s) billed, for one or more CPT codes or HCPCS Level II Code(s); or (iii) the physician received reduced payment based upon the application of Multiple Procedure Logic.
For purposes of the above, a copy of the relevant CIGNA HealthCare Remittance Form showing that payment was denied as submitted on the CPT Codes or HCPCS Level II Codes in question, in whole or in part, will be adequate. In the event that the physician cannot locate the CIGNA HealthCare Remittance Form, the physician may submit copies of internal accounting records (such as printouts of accounts receivable records or paid account records) if those records show for the underlying claim and specific date of service the CPT codes or HCPCS Level II codes that were submitted to CIGNA HealthCare for payment and those that remain unpaid.
- Clinical Information. In most cases CIGNA requires a complete copy of the relevant medical records.
1. The requirement that clinical notes, operative reports or other clinical information be submitted does not apply to requests for payment based on claims that:
- CIGNA HealthCare failed to recognize modifiers 50, RT, LT, FA-F9, or TA-T9, and thus denied payment for one or more CPT Codes as duplicative of other CPT Codes reported;
- HCPCS Level II "J" code was translated into an incorrect or overbroad CPT code.
For claims of the type, the physician must submit:
- A copy of the HCFA 1500 or other claim form used to submit the original claim to CIGNA HealthCare.
- Documentation showing that payment was denied, in whole or in part, for the CPT codes or HCPCS Level II Codes concerned (such as a copy of the relevant CIGNA HealthCare Remittance Form or the physician’s internal accounting records.)
2. The requirement that clinical notes, operative reports or other clinical information be submitted also does not apply to requests for payment based on the contention that CIGNA HealthCare incorrectly processed one or more modifier 51 exempt CPT Codes and/or add-on CPT Codes using Multiple Procedure Logic when those codes were exempt from multiple procedure reduction. For these claims the physician must submit a copy of the documentation showing that payment was denied, in whole or in part, for the CPT codes concerned. Such documentation may include a copy of the relevant CIGNA HealthCare Remittance Form or the physician’s internal accounting records.
C. Compensation for Erroneous Denials on Medical Necessity Grounds
Medical Necessity Denial Compensation may be sought for claims that the physician believes were improperly denied as not medically necessary or as experimental or investigational. If CIGNA denies the Proof of Claims it will automatically be sent to an external reviewer for a final decision.
a. Documentation showing that the physician submitted claims for payment to CIGNA HealthCare for services or supplies where payment was denied for one or more CPT Codes or HCPCS Level II Codes due to CIGNA HealthCare’s determination that the medical services, procedures or supplies corresponding to such codes were either not medically necessary or were experimental or investigational. The physician may submit the relevant CIGNA HealthCare Remittance Form. If the physician cannot locate the CIGNA HealthCare Remittance form applicable to a given claim, the physician may submit copies of internal accounting records (such as printouts of accounts receivable records or paid account records) if those records show that the CPT codes or HCPCS Level II codes in question were submitted to CIGNA HealthCare for payment and remain unpaid and To preserve the ability to submit Proofs of Claims under the Claims Distribution Fund, it is strongly recommended that physicians retain billing records and medical records dating back to August 4, 1990 (or up to 90 days prior to August 4, 1990 as described above).
b. A complete copy of the clinical information generated in connection with the services. Clinical operative or other medical records that relate to dates of service occurring more than 90 days before the date of service at issue in the Proof of Claim do not need to be submitted.
CIGNA Settlement Update - July 11, 2004
The Notice of Commencement of the claims period for the Settlement of the Class Action between CIGNA Healthcare and Physicians was mailed by the Settlement Administrator on July 8, 2004. Please read the notice carefully. You may be entitled to compensation under the terms of the settlement. The notice describes how to submit claims for compensation. The claims period will begin on August 23, 2004 and will end on February 18, 2005. A copy of the Notice is available at www.hmosettlements.com
Under the settlement, physicians may receive compensation from either one of two funds established by CIGNA 1) The Category A Settlement Fund or 2) the Claim Distribution Fund. The Claim Distribution Fund has three categories of compensation: Category One, Category Two and Medical Necessity Denial Compensation. If a physician chooses to seek compensation from the Category A Settlement Fund, he/she may not seek compensation from the Claim Distribution Fund. If a physician seeks compensation from the Class Distribution Fund, he/she may submit requests for payment in any or all three of the categories paid from the Fund.
Please note, once a physician submits a claim from either Category A or the Claim Distribution Fund, he/she may not change his or her mind. If a physician submits a claim under Category A, he/she will not be eligible to submit claims under the Claim Distribution Fund. While submitting a claim for Category A compensation is simple, for many physicians who experienced substantial denials of, or reductions in payments from CIGNA due to Claim Coding, bundling edits or adverse medical necessity determinations, the potential compensation from the Claim Distribution Fund may far exceed the amount that can be payable to an individual class member under Category A.
MSSNY is currently seeking vendors that will be able to assist MSSNY members in submitting claims during the CIGNA claims period. If a physician elects to submit a claim for Category A compensation, he/she may direct that his/her share be contributed to a not-for-profit foundation established by any medical society that signed the Settlement Agreement. MSSNY established and sponsors the Medical Educational and Scientific Foundation of New York, Inc. (“MES Foundation”).
MSSNY urges class members who submit a Category A claim to consider contributing his/her Category A share to the MES Foundation.