The jury is still out on whether a recent legal settlement and a pending settlement proposal satisfy a fundamental goal of the 19 medical societies that brought suit against nine giant, national health insurance carriers. The physicians' goal was to force health plans to make sense of a confusing array of claims processing edits and create a standardized system across all plans that would be fair to physicians.
On Oct. 24, U.S. District Court Judge Federico Moreno in Miami approved a settlement with Aetna, while Cigna still faces a Dec. 18 final approval hearing before Moreno.
The seven other defendant health plans, however, still show no signs of settling the doctors' lawsuits against them. Even the two recent agreements contain promises that are yet to be fulfilled, says Bohn Allen, M.D., who was on a committee at the Texas Medical Association that helped negotiate the Aetna settlement.
"There is a new atmosphere," Allen concedes, "but whether it is a better atmosphere is yet to be determined until we see how this all plays out."
A top official for Hartford, Conn.-based Aetna, which announced its agreement in May, says the payer is implementing the deal.
"Aetna is committed to simplifying and improving transparency in our claims-payment process and to paying physicians faster and with greater accuracy," says William Popik, M.D., chief medical officer of Aetna.
In September, Aetna launched new Web-based software developed by Atlanta-based McKesson Information Solutions. The product, Clear Claims Connection, tells doctors whether certain CPT codes would be paid for or bundled into other codes, and it explains the rationale behind the decisions.
But hundreds of Aetna's customized edits are not yet on the McKesson Clear Claims Connection Web site. To find these exceptions, a doctor must consult a separate list of codes on the Aetna Web site. But Popik promises Aetna will incorporate the exceptions into the Clear Claims Connection software by the end of the year.
The Aetna settlement also pledges a few specific changes in claims editing, such as limiting multiple-surgery reductions and paying physicians for extra services done during a preventive office visit.
The company is also committed to creating claims editing software "acceptable to physicians and health plans" and "a mutually acceptable process" of updating that software, the settlement says.
This would bring medical societies one step closer to their cherished dream of one standardized system of edits, says David Cook, executive director of the Medical Association of Georgia, which claims to have filed the first of the medical societies' class action suits against the health plans in 1999.
"A big part of doctors' lives would be much simpler if all the payers used the same coding logic," says Cook, who is an attorney.
But Cook concedes the recent agreement doesn't quite reach the goal. The document gives Aetna the right to continue using its own customized edits until three-quarters of medical societies and health plans, based on their share of total membership, endorse a standardized system.
That is a daunting challenge, even though McKesson reports that other, unidentified payers also have committed to using Clear Claims Connection, which could become the basis of a standardized system.
But so far, other plans-including the largest defendant, Minnetonka, Minn.-based UnitedHealthcare-still refuse to settle with the medical societies.
Philadelphia-based Cigna Corp. has signed a settlement that is still pending in federal court. Medical society representatives report it contains concessions on its own claims editing that are more generous than Aetna's. But the Cigna settlement, which was announced after the Aetna agreement was reached, does not include Aetna's provision for accepting a standardized system for all health plans.
The reason, several sources close to the negotiations say, is that representatives for the Federal Trade Commission warned that bringing together plans and medical societies to discuss a common system of coding edits might be an anti-competitive practice violating federal antitrust laws.
Representatives for Cigna and the FTC declined to address this report, and an attorney for the medical society that dealt with the issue could not be reached for comment.
Richard Raskin, a Chicago-based antitrust attorney who was not a party to the settlements, says he is not surprised that the FTC would have such concerns. He says coding edits such as bundling can affect physicians' fees, and fee-fixing is an antitrust violation.
On the other hand, Raskin and others concede that the AMA-CPT panel and medical societies such as the American Academy of Orthopaedic Surgeons already bring doctors together to set standards on what codes should be bundled and what should not be.
Raskin adds that putting a standardized system in the settlement agreement that must be approved by federal courts may give it a "judicial stamp of approval," although he concedes that the FTC has rejected that argument.
With such murky questions still hanging over the settlements, it's no surprise that even physicians as well-versed in the negotiations as Allen are unsure that anything will change.
Allen recalls that in the past, organized medicine made a lot of agreements with managed care companies and "nothing ever happened. It didn't translate from the leadership to the average worker bee in the insurance company," he says.