Aetna announced yesterday that it has agreed to pay up to $6.27 million and improve its claim-paying practices to settle a lawsuit potentially involving tens of thousands of dentists.
The nationwide lawsuit, filed by the American Dental Association and three individual dentists two years ago, accused Aetna of improperly denying, reducing and delaying claim payments.
The dental association represents about 147,000 dentists nationally. But the number of dentists who will participate in the settlement isn't known.
The latest accord, which is subject to court approval, will provide $4 million in payments to dentists, and $1 million to the ADA Foundation. Dentists can choose to give their portions of the settlement to the foundation.
Aetna also will pay up to $1.25 million to plaintiffs' attorneys, and $7,500 to each of the three individual dentists who represented dentists nationwide. The lawsuit had not been certified yet as a class action, but both sides will ask for certification for the purposes of a settlement.
The agreement, in which Aetna denies the allegations, follows an announcement in May of the company's $470 million class action settlement with physicians. That settlement, also subject to a judge's approval, involves $170 million in cash and $300 million in improvements in business procedures.
Dates to 1995
The latest agreement would cover dentists who served Aetna members from Aug. 15, 1995, through the day a judge gives preliminary approval to the settlement. The agreement will be submitted within a few days to Judge Federico A. Moreno in U.S. District Court in Miami, and a hearing would then be scheduled, said Aetna spokesman David Carter.
Aetna has 11.3 million dental members nationally.
"This agreement marks another important step in Aetna's efforts to lead the industry in building a more efficient health care system and strengthening our working relationship with the health care community," said Dr. John W. Rowe, Aetna's chairman and chief executive, in a written statement.
Aetna, one of many managed care companies sued by doctors, was the first to settle the major class action litigation with physicians. The insurer, which is based in Hartford, has been making headway in its financial turnaround and in bettering its relationships with health care providers.
The ADA filed a racketeering suit in May against CIGNA, MetLife and Mutual of Omaha, accusing them of shortchanging dentists on pay. CIGNA spokesman Wendell Potter said his company isn't currently in settlement talks with the dentists.
In the Aetna lawsuit, the ADA alleged dentists' bills were manipulated to reduce the amount the insurer would pay. In "bundling," for instance, an insurer combines two or more items on a bill into one. In "downcoding," the insurer changes the codes for services on a bill to codes that entail lower reimbursement.
Aetna agreed not to engage in automatic downcoding or bundling, but reserved the right to reduce inappropriate billing in some cases. The company will post on its Web site its methods relating to those reimbursement practices.
The company also agreed to pay "clean" claims - those with all the necessary information and codes - within 15 days if submitted electronically, and 30 days for paper claims.
The Hartford Courant is a Tribune Publishing newspaper.