Humana, Inc., which recently agreed to a $3.5 million settlement as part of the Solomon v Anthem, et al., class-action suit, has released information on how chiropractors and other non-MD providers can submit claims for compensation. Humana is one of 10 managed care companies accused of conspiring to underpay doctors of chiropractic and other non-MD providers by denying reimbursement for medically necessary treatment.
To recover claims, class members - defined as health care providers, groups and organizations that provided covered services to Humana insureds between Jan. 1, 1990, and Aug. 16, 2006 - must submit a claim no later than Jan. 13, 2007; the claim must include an estimate of the total billed charges.
The $3.5 million fund will be divided pro rata among class members who submit valid claims by the above deadline. The amount dispensed will be determined by the total dollar value of claims and the number of class members submitting claims.
As part of the settlement agreement, doctors of chiropractic can assign 100 percent or 50 percent of their recovery to the American Chiropractic Association. The ACA participated through counsel in the settlement discussions and is a signatory to the agreement, which stipulates that Humana appoint an ACA representative to the company's newly formed health care provider advisory committee. This stipulation is intended to establish a means of direct communication on any future issues and concerns regarding appropriate reimbursement for chiropractic services.
Class members have been mailed a notice explaining their rights under the settlement, along with a claim form and instructions. Additional information on the claims submission process is available at www.pddocs.com/humanaprovidersettlement. A copy of the entire settlement agreement is available online at www.acatoday.com/pdf/Humana_ Settlement.pdf.
Filed in October 2003, the Solomon suit alleges that Humana and other managed care companies, including Anthem, Health Net, Aetna, Wellpoint Health Networks, Prudential, Coventry Health Care, and the newly merged United Healthcare and PacifiCare Health Systems, violated the Racketeer Influenced and Corrupt Organizations (RICO) Act by systematically refusing to compensate health care providers for covered services; processing health care providers' claims using automated programs, which manipulate standard coding processes, or using unqualified personnel to determine whether the service provided was medically necessary and covered; downcoding and bundling legitimate claims to less costly procedures; arbitrarily refusing or reducing payment for certain categories of treatment; systematically failing to recognize valid assignments of benefits; and delaying payments by requesting additional documentation, even when such documents were not required.
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