RICO Resource Center (June 11, 2007)

Welcome to CMA's RICO Resource Center. Click on the table of contents for information on various aspects of the RICO class action lawsuit.

Action Items - NEW! IMPORTANT BLUE CROSS OPT-OUT INFORMATION!

UPDATED! ADDITIONAL AETNA DEADLINE INFORMATION!

1. Settlement Information
   • Enforcement (Updated!)
   • Humana Settlement
   • WellPoint/Anthem Settlement (Blue Cross of California)
   • Health Net Settlement
   • CIGNA Settlement
   • Aetna Settlement (Updated!)
2. Physicians' Foundations
3. CMA Press Releases and Articles

The RICO class action lawsuit won another significant victory this summer when Anthem/WellPoint settled with physicians. It is the fifth major insurance giant to settle with CMA and the other plaintiffs. Through this and previous settlements, physicians will receive more than $344 million in cash payments from health plans and court-ordered reforms valued at more than $1 billion. Click here for CMA's RICO Settlements At-a-Glance document.

CMA started the case five years ago, challenging the rapacious tactics of the for-profit managed care industry. The case allowed physicians to air profound grievances against an industry that has arrogantly and unfairly exploited them for well more than a decade.

As a federal appeals court said in 2004: “It would be unjust to allow corporations to engage in rampant and systematic wrongdoing, and then allow them to avoid a class action because the consequences of being held accountable for their misdeeds would be financially ruinous.”—11th Circuit Court of Appeals, September 1, 2004.

The suit grew to become the largest class-action health care lawsuit filed in the United States, with more than 800,000 physicians and 19 state and county medical associations joining CMA as plaintiffs. The suit alleges that the defendant health plans—WellPoint, PacifiCare, Health Net, Aetna, CIGNA, United, Anthem, Coventry, Humana and Prudential—have engaged in fraud and extortion in a common scheme to wrongfully deny payment to physicians, in violation of federal civil racketeering law. The case is being heard before Judge Federico Moreno in federal district court in Miami and is set for trial in January.

IMPENDING DEADLINE INFORMATION

DEADLINE JANUARY 2007! Blue Cross-contracted physicians have until January 21st, 2007 to opt-out of Blue Cross workers' compensation networks. If you opt-out, you will still be free to negotiate separate contracts with Blue Cross to provide workers’ comp services. Deadline for resubmission of claims is January 21, 2007! See below for more information:

1. Blue Cross Workers' Compensation Opt-Out Letter (view the letter)

DEADLINE APRIL 2007! Thanks to CMA advocacy, from January 1, 2007 through April 30, 2007, Aetna will reimburse physicians for E&M services when billed with modifier 57, performed on the same day as a decision for major surgery (global, 90-day procedure). Deadline for resubmission of claims is April 30, 2007! See below for more information:

1. Aetna Claim Article (view the article)
2. Aetna Claim Certification (view the certification template)
3. Claim Resubmission Worksheet (view the worksheet)

DEADLINE DECEMBER 2007! CMA and representatives from various state medical societies have succesfully resolved another RICO settlement dispute. From June 1, 2007 through December 1, 2007, CIGNA has agreed to retroactively pay previously denied claims with add-on codes for computer-aided digital (CAD) mammography, originally submitted between January 1 and October 10, 2004. Deadline for submitting claims is December 1, 2007! See below for more information:

1. CIGNA Claim Article (view the article)
2. CIGNA Spreadsheet for Resubmitting Previously Denied Add-On Code Claims (view the spreadsheet)

SETTLEMENT INFORMATION

Enforcement

1. The CMA Enforcement Toolkit (Updated!) (view the toolkit)
2. Overview of RICO Settlements (view the summary)

Humana Settlement

1. The Humana Settlement Notice (view the notice)
   • Humana Affiliated Entities List (view the affiliated entities list)

WellPoint/Anthem (Blue Cross of California)

1. The WellPoint Settlement Agreement (view the agreement)
2. Summary of the WellPoint Settlement (view the summary)
   • Attachment A (settlement commitment start dates) (view the attachment)

Health Net Settlement

1. The Health Net Settlement Agreement (view the agreement)
2. Summary of the Health Net Settlement (view the summary)
   • Attachment A (settlement commitment start dates) (view the attachment)

CIGNA Settlement (Updated!)

1. The CIGNA Settlement Agreement (view the agreement)
2. Summary of CIGNA Settlement (view the summary)
3. A Step by Step Guide to Resolving Billing Disputes (view the guide)
4. A Step by Step Guide to Resolving Settlement Compliance Disputes (view the guide)
5. NEW! CIGNA Spreadsheet for Resubmitting Previously Denied CAD Mammography Services Claims (view the spreadsheet)

Aetna Settlement (Updated!)

1. The Aetna Settlement Agreement, Section 7 (view the agreement)
   • Exhibit H (settlement commitment start dates) (view the exhibit)
2. A Step by Step Guide to Resolving Billing Disputes (view the guide)
3. NEW! Aetna Urinalysis Dipstick and Pulse Oximetry Coding Change (view the article)
4. Settlement Compliance
   • NEW! A Summary of Successful Aetna Compliance Disputes (view the summary)
   • Aetna Participating Physician Contract Addendum Reflecting Settlement Terms (view the addendum)
   • Aetna Letter to Physicians Regarding Contract Addendum (view the letter)
   • A Step by Step Guide to Resolving Settlement Compliance Disputes (view the guide)
   
   
5. Other Resources
   • CMA's RICO Recovery Guide: Maximize Your Share of the CIGNA and Aetna Settlements (view the guide)
   • A CMA Video Presentation on the Aetna and CIGNA Settlements (view the presentation)
   • CMA PowerPoint Presentation on the Aetna Settlement (view the presentation)

PHYSICIANS' FOUNDATIONS

The Physicians’ Foundations set up under these settlements have more than $100 million on deposit, with more to come. The foundations are dedicated to forward-looking research and development that improve practice viability and make it easier for physicians to provide quality medical care to their patients. CMA CEO Jack Lewin, M.D., is vice chair of both these foundations.

For more information on the Physicians’ Foundations, go to the Physicians' Foundations Website.

CMA PRESS RELEASES AND ARTICLES

1. CMA's RICO Lawsuit July 21, 2005 summary from Physician Leader, CMA's quarterly publication view the article
2. CMA Alert, September 2, 2004:
   Class Certification of RICO Case Upheld [SUMMARY] [FULL OPINION]
3. CMA Press Release, Sept. 26, 2002:
   RICO Class Action Ruling a Big Win for HMO Patients and Doctors
   (view the order)
4. CMA Press Release, Mar 15, 2002:
   Physicians Receive Favorable Ruling on Arbitration
   Appeal in RICO Lawsuit Against For-Profit HMOs
5. The Amended RICO Complaint
6. CMA Press Release, May 23, 2001:
   Federal Judge Orders Discovery In Landmark HMO Case
7. CMA Press Release, May 7, 2001:
   Class Certification Hearing Notice: National HMO Racketeering
   Cases In re Humana, Inc., Managed Care Litigation
8. CMA Press Release, March 26, 2001:
   California Joined by Texas and Georgia Medical
   Associations in Federal Lawsuit Against Health Plans
9. CMA Press Release, March 5, 2001:
   CMA Receives Encouraging Ruling in RICO Case Against For-Profit HMOs
10. CMA Press Release, May 25, 2000:
    CMA Files Suit for Injunctive Relief Against
    Major Health Plans Under Federal RICO Laws