Physicians Nail CIGNA
For years, rheumatologists in Oregon have been battling down-coding and claim denials from CIGNA, one of the nation’s largest health insurers. Two physicians in the Midwest got tired of getting the runaround in regard to claim denials and did something more than complain; they filed a lawsuit. Timothy Kaiser, MD, an ENT physician from Alton, Illinois and Suzanne Corrigan, MD, a pediatrician from Irving, Texas sued CIGNA for wrongfully denying claims and using a software program to arbitrarily bundle and down-code claims. The suit eventually became a class action law suit and in November CIGNA decided to settle out of court in a settlement that could result in payments to physicians totaling anywhere from 60 to 200 million dollars. The disputed claims date back as far as 1996. For more information on the proposed settlement, go to www.CIGNA-classaction.com.
Many groups now involved with similar claims believe that the settlement didn’t go far enough and are unhappy. In a related legal aspect, the settlement may be overturned as there is a jurisdictional dispute regarding which court should be hearing the case. Further work regarding a settlement may be moved to a Florida Federal Court, but the message is clear: a persistent physician can make a difference.
Shortly before they announced the settlement, CIGNA announced a net loss of $877 million for the third quarter earnings. CIGNA Chair H. Edward Hanway blamed pricing “misjudgments” in the face of stiff competition, along with increased spending in order to raise service levels. Its plans for cost-reduction include job cuts and other administrative changes, which physician advocates feel will make the administrative hassles with this company even worse.
Company stock dropped from over $100/share down to $30/share with the announcement. CIGNA insures more than 13 million lives and earned revenues of $14.2 billion dollars in 2001.
Kitzhaber's Parting Gift to Medically Needy
Governor Kitzhaber’s administration ended the program called “Medically Needy” on Dec 31st 2002, Benefits expire on January 31st. In early January, patients who are medically disabled and on Social Security Disability received a letter stating that the program had been discontinued and that no hearings could be granted as the program had been terminated.
For many patients who are disabled on Social Security, the OHP previously paid for his or her medications under a program called the “Medically Needy.” Because medication coverage for prescriptions is not available under SSI disability or Medicare, these disabled patients, (many of our most disabled and poverty level arthritis patients) will be without medication. Both patients and physicians were surprised with the rapidity of this unanticipated change which left little time for patients to develop other strategies.
In other drastic changes indicative of the Oregon Health Plan’s continuing problems, the Basic Benefits Package will be dramatically restricted and, in a marketing move, be renamed OHP Plus. The majority of those previously on the Basic Package will be moved to a new reduced package and be required to furnish co-pays for visits andmedications. The new package called OHP standard will include some reduction in the Prioritized List of Health Services. It will not include routine vision, or eye check-ups, hearing aids, or one-time medical supplies like crutches for a broken leg. In the preliminary document, no mention was made about crutches for use after joint surgery or replacement. OHP Standard patients may have a premium or increased premium in addition to his or her co-pay and, if this premium is not paid on time, all clients in the household will lose their OHP coverage and will have to endure a six month waiting period before reapplying. The vaulted OHP model may soon be known as the infamous OHP plan.
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Daiichi Grants ORA Fellow Travel Scholarship
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Let the Consumer Decide?
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ORA Attracts National Speakers to Winter Meeting
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Rheumatology National Advocacy Roundtable in Portland
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