How to collect on class-action lawsuit settlements

I was told that Aetna has settled a lawsuit related to underpayment of out-of-network physicians, and other payers were soon to follow. How do I collect on the monies due me from the class-action settlement?

As you are aware, there have been a few class-action lawsuit settlements that have been settled in favor of or that will result in money back to physician groups. Cases that have been settled in the past include the Deepwater Horizon Economic and Property Damages Settlement, Visa/MasterCard credit card fee overcharges, Ingenix UCR data, and others. Aetna is the latest to reach a settlement, and Cigna is expected to settle this fall.

Each case is slightly different in its requirements. For the Aetna case, it appears that you need only prove that you were an out-of-network provider for any year between 2003 and 2012. For each year you were an out-of-network provider, you can be paid a fee depending upon the number of physicians seeking payment (approximately $40 per year). For other cases, including the Deepwater Horizon and Visa/MasterCard cases, you have to identify the claims/transactions that you think you were underpaid and submit them to the settlement group, which will then write you a check for the difference of all verified claims in the class.

In many cases, you have the option of recouping revenue from previous practices/business structures that you no longer report, as long as you can provide the data. This explanation is somewhat simplified as far as legal red tape, but we have seen many recover money due that far exceeded the cost of the recovery.

If you do not have access to all of your records going back through eligible dates, or you are looking for an alternative to digging through all of your records and filling out the forms, there are groups that can do this for you. Managed Care Advisory Group is one such group that will do this on a contingency fee only. Physician Reimbursement Systems was introduced to this company by a urologist. It specializes in the recovery of settlement money, and we are told it’s very good at what it does.

PRS has signed an agreement with the group to offer discounted rates to urologists for assisting in promoting the service, and you may find more information on the service at www.mcaginc.com or on www.prsnetwork.com.

For urethral catheterization with extensive bladder irrigation and clot evacuation, the work involved is far more complex and time consuming than simple bladder irrigation/lavage (51700). What is the best way to code for the above complex clot evacuation procedure without cystoscopy in office and hospital settings?

Code 51700 (Bladder irrigation, simple, lavage, and/or instillation) is the most accurate code available for the service you describe. The only option we see to report the additional work and perhaps increase the reimbursement is to use modifier –22 appended to the code. Remember, when using the –22 modifier, you will likely be required to submit documentation to support the use of the modifier.

We recommend time-based referencing to the increased work effort as a percent increase in effort. For example, bladder irrigation of the patient required an increase of 50% in time and materials to complete the irrigation.

Use of the –22 modifier does not guarantee extra payment but might result in additional pay. We have noticed a pattern of payer payment at a percentage above normal, ranging from 20% to 30% for many payers, if documentation supports this increased work effort and the modifier usage is not excessive.UT

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