Payer Settles, You Win

Is there any hope for improving the acrimonious relationship between you and your patients' insurers? The legal settlement between Aetna and a group of 20 physician medical associations looks like a positive sign. 

This spring Aetna broke ranks with nine other large insurance companies and agreed to settle a huge class action lawsuit brought by the associations on behalf of virtually all U.S. physicians.

To demonstrate to Wall Street that it was both a smart business move and good for consumers, Aetna trumpeted the settlement in Wall Street Journal ads, promising to usher in a new era of "openness, cooperation, and collaboration." The settlement will free up Aetna to build its business and stop spending millions of dollars in legal defense fees.

In the end, this should reduce the time physicians spend jumping through sometimes impossibly high hoops to get paid for the services they provide. If the settlement holds up, and is joined by other insurers, it will affect both your patients' care and your pocketbook. But perhaps more important, say physicians' lawyers, going forward, Aetna agreed to change many policies detested by physicians.

For example, patients insured by Aetna will be entitled to receive "medically necessary care as determined by a physician exercising clinically prudent judgment in accordance with generally accepted standards of medical practice." Less expensive alternatives will be permissible only when they are "at least as likely to produce therapeutic or diagnostic results." This is, of course, how it should be.

In addition, the two sides agreed that E&M codes will not be automatically downcoded. Aetna agreed that it would publish its physician fee schedules on the Internet by the end of 2004. Finally, the case will stay active before a federal judge for four years to provide for prompt resolution of future conflicts between physicians and Aetna.

But even these changes may not be significant unless they are applied across the board to payers. Behind the scenes, settlement discussions continue while insurers weigh the likelihood of losing in court and the costs of their defense.

Physicians' lawyers are pushing hard, asking a federal judge to allow their lawsuit to go forward under a class action RICO (Racketeer Influenced and Corrupt Organizations Act) claim. If they succeed at trial, payers could be liable for billions of dollars to physicians who've long felt backed into a corner.

When the legal maneuvering ends, whether through more settlements or court actions, physicians, their patients, and the healthcare system just might be in for some relief.

Politics and Your Practice is written by Ken Karpay, JD, CMC, associate publisher of Physicians Practice and a management consultant. He can be reached at kkarpay@physicianspractice.com.

This article originally appeared in the July 2003 issue of Physicians Practice.