MORENO APPROVES AETNA AGREEMENT IN PHYSICIAN CLASS ACTION.U.S. District Judge Federico Moreno of Miami has approved a settlement agreement between Aetna and about 950,000 doctors. Moreno delayed ruling Oct. 14 on the settlement after lawyers for some of the doctors opposed the settlement. The lawyers claimed they had not received adequate notice of the deadline for deciding whether their clients should opt out, that they had not been provided with sufficient detailed information about the settlement before the opt-out deadline and that new state and federal laws made some of the provisions of the settlement unnecessary. This is the second settlement Moreno has approved between the doctors and a health maintenance organization. He approved a similar agreement between Cigna and the doctors in September. Aetna has estimated the total cost of its agreement at $470 million, including $300 million in benefits and $100 million in cash payments to the doctors as well as $50 million for legal fees and $20 million for a health care foundation to be run by the doctors to reduce medical errors, childhood obesity childhood obesity Public health Overweight in a child, an average BMI of ≥ 85% for age and sex; ≥ 95% for age and sex is very obese. See Body-mass index, Obesity. Cf Adult obesity. and racial disparities. The doctors also are to be allowed to take any billing disputes to an independent, external board. Cigna estimated its agreement would cost $500 million, with doctors receiving $85 million in cash payments. The class action was filed against Aetna, Cigna, Humana, Foundation Health Systems, United Healthcare, Prudential and Wellpoint. The doctors claimed the insurers had engaged in a conspiracy and common course of fraudulent The description of a willful act commenced with the Specific Intent to deceive or cheat, in order to cause some financial detriment to another and to engender personal financial gain. conduct in which they automatically delayed, denied and downcoded payments to doctors. They also claimed that making payments on a basis other than the medical necessity definition contained in their agreements with the insurers constituted a pattern of racketeering Traditionally, obtaining or extorting money illegally or carrying on illegal business activities, usually by Organized Crime . A pattern of illegal activity carried out as part of an enterprise that is owned or controlled by those who are engaged in the illegal activity. activity and that failing to pay their claims, or the downcoding of their claims according to according to prep. 1. As stated or indicated by; on the authority of: according to historians. 2. In keeping with: according to instructions. 3. a new standard other than medical necessity, was a breach of contract. They also questioned whether the insurers had agreed to lower reimbursement Reimbursement Payment made to someone for out-of-pocket expenses has incurred. rates and/or slow payment schedules in a conspiracy to keep reimbursements low. After Moreno ruled Sept. 26, 2002, the doctors had established the necessary similarity Similarity is some degree of symmetry in either analogy and resemblance between two or more concepts or objects. The notion of similarity rests either on exact or approximate repetitions of patterns in the compared items. among their claims to be certified See certification. for class action and set trial for May 19, the insurers appealed to the Eleventh In music or music theory an eleventh is the note eleven scale degrees from the root of a chord and also the interval between the root and the eleventh. Since there are only seven degrees in a diatonic scale the eleventh degree is the same as the subdominant and the interval Circuit Court of Appeals. |
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