Class action lawsuits.

The fictional scenario depicted in this installment of PRACTICE MANAGEMENT CLINIC illustrates the insurance-carrier lawsuit-settlement status in a solo ENT practice (figure). Aetna and CIGNA have settled lawsuits; Anthem, Coventry, Humana, and UnitedHealthcare are in settlement discussions; and Health Net and Prudential have filed appeals, with a decision expected in December 2005. Aetna paid a different amount to each provider ($163.11 in this case) because providers did not have the option of submitting separate appeals based on their individual losses. CIGNA, on the other hand, did offer providers this opportunity, and the difference between what Aetna and CIGNA paid was substantial, at least in this example. If the other providers settle, your practice should carefully analyze the amount of time and money that might be required to obtain the payment that you are owed. Most likely, the amount reimbursed will not be even close to the amount that was lost.

It is important to track your carriers with regard to denials, contract variances, etc., and to catch discrepancies early. Early discovery will likely lead to a better recovery rate or the opportunity to demonstrate egregious practices before your practice suffers substantial losses.

Steven F. Isenberg, MD

Dr. Isenberg is an otolaryngologist in private practice in Indianapolis; [e-mail]

Figure. Chart shows the current settlement
status of several class action lawsuits.

Carrier             Recoupment to date

Aetna               $163.11
Anthem              In settlement discussion
CIGNA               $7,026.78
Coventry            In settlement discussion
Health Net          Open to appeal; est. 12/05
Humana              In settlement discussion
Prudential          Open to appeal; est. 12/05
United Healthcare   In settlement discussion