MDs Win Second Victory ... Chiropractic Still Fighting

From the pages of the Sept. 22/29, 2003 issue of the American Medical News (AMNews) comes an article announcing the second victory by MDs over managed care payers.¹ The first victory occurred just a few months earlier, when Aetna settled out of the same lawsuit brought by medical doctors across the country against 10 managed care companies for denying or downgrading their reimbursement claims.

Aetna got out of the case with a $470 million settlement that included paying $100 million to the doctors; $20 million to a research foundation; $50 million in attorney's fees; and agreeing to change the way its medical bills are paid, which will cost $300 million more over several years.²

In this second victory, CIGNA expects to pay $140 million to MDs and another $400 million in "other improvements in services," which will likely increase the amount MDs are paid for their claims. According to the AMNews article, CIGNA has agreed to:

• contribute $15 million to a state medical society-run foundation established for public health improvement initiatives;
• appoint an external party to resolve billing or payment disputes;
• pay physicians a fee to administer vaccines and other injectable drugs, on top of paying for the drugs;
• create a physician advisory committee to garner physician input;
• no longer require physicians to submit copies of medical records to get paid for most office visits occurring on the same day as surgeries or other procedures;
• pay interest on fully documented claims that aren't paid within time limits established by the settlement; and
• pay up to $55 million in legal fees, as determined by the court.

In addition to the over $1 billion already won by the MDs, there are several more defendants (United Health; Wellpoint Health; Humana; Anthem; Foundation; Prudential; Pacific Care; and Coventry) that could end up paying even more money to the MDs before the case is finished. And while the initial millions are appreciated, it is clear by the comments coming from the AMA that the real boon will be increased reimbursements for their members.

Dentists have also sought to resolve payment issues with managed care companies in a similar manner. On May 19, 2003, the American Dental Association (ADA) brought a lawsuit against five managed care companies (including CIGNA) under the RICO (Racketeer Influenced and Corrupt Organization) laws.³

This trend in class-action lawsuits against managed care companies appears to not only be necessary, but also successful. The MDs and the dentists have both determined that the courts were the only place they could be heard and receive the justice they sought. In the case of the MDs, justice is already being expressed in the billions of dollars.

Should chiropractic expect to have to file a lawsuit in order to gain fair treatment? Do you think the Trigon Blue Cross/Blue Shield lawsuit isn't necessary? The actions of the AMA and the ADA should tell you otherwise.

Sadly enough, we live in a time in which doing the right thing is an economic - not a moral - decision. As has been seen over and over again, large organizations act according to the bottom line, not the results their actions (or inactions) may have on individuals and their health.

The decision of whether to pay or not pay your claim - or the amount of money to pay you - isn't based on whether you are a good doctor, or if they like you. In many cases, it may be purely an economic decision.

What about the health and welfare of your patients? That's your responsibility, not that of the payers. They are only required to redistribute money, and hope to make a handsome profit doing so. You are the one who bears the burden of insuring the health of your patients.

We are currently preparing information that will help you realize just how important the Trigon lawsuit is, not only in changing the way doctors of chiropractic are reimbursed, but also in fighting the prejudicial treatment that has so hindered the growth of our profession.

Don't believe it? In an upcoming issue, we will trace the roots of the Trigon lawsuit back to the AMA's actions to "contain and eliminate" chiropractic. After you see the evidence, only then will you understand.

References

1. CIGNA settles class-action suit on pay issues. AMNews Sept. 22/29, 2003.
2. Aetna agrees to settle suit with doctors. USA Today, May 22, 2003.
3. ADA leads the way: Is this the solution to managed-care abuses? Dynamic Chiropractic June 3, 2003. www.chiroweb.com/archives/21/14/16.html.

DMP Jr.