Doctors in Class Action Suit Against Aetna, CIGNA
Health Data Management Magazine, April 1, 2009
The American Medical Association, five state medical associations and several physicians have filed two class-action lawsuits against Aetna Inc. and CIGNA Corp., alleging under-reimbursement of physicians.
The two lawsuits, filed Feb. 9, contend that for more than a decade, the two health insurers used an unfair system to underpay physicians for out-of-network services, leading patients to pay an excessive portion of costs. The underpayments, they allege, stem from relying on skewed data from Ingenix, an Eden Prairie, Minn.-based subsidiary of UnitedHealth Group.
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The suits, filed in partnership with the state medical societies in Connecticut, New Jersey, New York, North Carolina and Texas, seek payment for the physicians who were underpaid based on the data. They are also seeking reform of the two insurers' payment systems for out-of-network services.
In January, the AMA and the Medical Society of the State of New York and the Missouri State Medical Association settled a lawsuit against UnitedHealth Group that the group filed in 2000 regarding the use of Ingenix data. Under that financial settlement, UnitedHealth agreed to pay $350 million.
Also in January, UnitedHealth Group and Aetna reached an agreement with New York State Attorney General Andrew Cuomo, who had been investigating the integrity of the Ingenix database. Under that agreement, United and Aetna agreed to fund creation of an independent database run by a not-for-profit organization to determine out-of-network reimbursement rates. United agreed to close the Ingenix database and pay $50 million to create the new, independent database. Aetna agreed to provide $20 million in funding.
An AMA spokesman said its latest lawsuit will, in part, help ensure that the Cuomo case's ban on future use of Ingenix data is applied nationally.
In a prepared statement, executives at Aetna said, "We're disappointed the medical community has chosen to litigate on top of already pending consumer litigation on the topic. If everyone believes they are entitled to additional payments, the health care system as a whole will bear the burden. Aetna has developed much improved relations with physicians over the past several years and would prefer to continue collaborative dialogue with them on this topic."
In its statement, CIGNA claimed the class action suit "is without merit." It stated, in part, "CIGNA used Ingenix data to determine reasonable amounts to pay for the small percentage of claims submitted for services provided by non-contracted health care professionals. CIGNA disclosed to doctors and consumers its use of the third-party Ingenix database as the basis of its out-of-network rate calculation. The use of the reasonable and customary methodology is a valuable method for our customers to manage costs and reduce upward pressure on the premium rates paid by individuals while maintaining access to a broad array of doctors.
"CIGNA's payments to out-of-network doctors are fair, and greater transparency in regards to physician pricing will prove that," the statement continued.
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