Cigna projects a fourth quarter charge of $50 to $65 million to pay for the settlement; some plaintiff attorneys said the figure could be closer to $200 million. It is unclear at this point whether Cigna will have to raise its rates to make up for the settlement costs.
Attorneys representing a number of medical societies and physician groups allege that a software system utilized by Cigna, and over 450 other health plans, called ClaimCheck, has been improperly reducing or ignoring doctor claims.
ClaimCheck screens claims submitted by physicians for certain combinations of procedures, then changes or eliminates payments for procedures considered fraudulent, unnecessary or erroneous. Physicians claim this results in Cigna paying less than was originally billed.
Terms of the Deal
The settlement was proposed by Cigna which, without admitting any wrongdoing, said, “[their] claims processing actions over the years have been appropriate.” Terms of the proposed settlement include:
- The appointment of a third-party administrator by Cigna to review denied claims since January 1996 to determine what, if any, amounts physicians are owed.
- Disclosure on Cigna’s Web site of the rules utilized by the software to cut bills; something physicians have claimed was secret in the past.
- No longer requiring physicians to submit medical records any time a patient has more than one procedure performed on the same day.
Final costs will vary based on the number of physicians who file claims for denied payments.
Attorneys for the physicians are not happy with the settlement, and have an opportunity to complain to the court. Objections to the settlement include Cigna’s continued use of the software and the difficulty physicians will have in obtaining money withheld for their services.
The settlement, which could have implications for health insurers who use this and similar software for medical claims processing, is still awaiting final court approval.