News: Pay for out-of-network care-the battle continues

May 1, 2009

Lawsuits were filed in NJ against Aetna and Cigna, alleging flawed database to intentionally shortchange out-of-network physicians.

The American Medical Association and state medical societies filed class-action lawsuits in New Jersey against Aetna and Cigna, alleging that the carriers use a flawed database to intentionally shortchange out-of-network physicians, which violates federal racketeering and antitrust laws, as well as federal health insurance laws. A report in American Medical News (2/23/09) notes that the database in question was created by Ingenix, a subsidiary of UnitedHealth Group, which recently settled a similar case in New York state.

United agreed to contribute money toward a new, independent database, as have Aetna and Cigna. But unlike United, Aetna and Cigna have not agreed to reimburse doctors for underpayments related to the old database. If the suits against Aetna and Cigna are resolved in physicians' favor, doctors who were paid for out-of-network care could be compensated for alleged shortfalls. Cigna and Aetna maintain that their payments were fair and have vowed to fight the legal actions.