How to file a claim, other details about the nationwide class action lawsuit settlement by Humana

Answers to your questions about filing a claim with the Humana settlement fund — including who is eligible, what to submit and what to expect from the process

by Legal and Regulatory Affairs

December 20, 2006 — This question-and-answer (Q & A) document addresses questions you may have about filing a claim with the fund created by Humana’s August 2006 settlement with a nationwide class of psychologists and other nonphysician health care professionals. The settlement fund is available to psychologists who — between January 1, 1990 and August 16, 2006 — provided covered services to patients insured by any defendant in the case. (More information about settlement fund eligibility, including a list of managed care company defendants, appears in answer 1 below.)

The deadline for filing claims is January 13, 2007. Submitting a claim is straightforward, and the process will be very familiar to those psychologists who submitted claims to the CIGNA settlement fund in 2005. See the second Q and A below to access a copy of the claim form.

The following questions are answered in this document:

Information about filing a claim and receiving payment

  • Who is eligible to file a claim?

  • How do I submit a claim to the settlement fund?

  • What if I did not submit claims for covered patient services to Humana (or other defendants); instead, my patients submitted the claims?

  • How will the settlement fund be divided among claimants?

  • Why is the settlement fund available to psychologists who only provided services to patients covered by other defendant companies besides Humana?

Other questions about the settlement and litigation

  • What are the policy changes in the settlement?

  • What is the Practice Organization’s relation to the settlement?

  • Are class members allowed to exclude themselves from the settlement?

  • What happens next with the settlement and how will I learn about future developments?

  • What should I do if I still have questions about the settlement, including how to access the available funds?

Information about filing a claim and receiving payment

1. Who is eligible to file a claim?

The Settlement Fund is available to you as a psychologist if between January 1, 1990 and August 16, 2006 you provided covered services to a Humana member or to anyone covered by a plan offered or administered by the other defendants in this case.

The other defendants are: Aetna, Inc., Aetna-USHC, Inc., Anthem, Inc., CIGNA, United Health Care, United Health Group, Wellpoint Health Networks, Inc., Pacificare Health Systems, Inc., Prudential Insurance Co. of America, Coventry Health Care, Inc., and Health Net, Inc.

Humana subsidiaries. You are eligible if you provided covered services to a member of any Humana subsidiary or affiliate involved in insuring or administering health benefit plans, including ChoiceCare Corporation, Emphesys Insurance Company and Employers Health Insurance Company.

Exclusions from eligibility. You may choose to exclude yourself from the settlement, as discussed further in Question 8 below. You are automatically excluded from the settlement if you: 1) submitted your claims solely through a physician or physician’s group; 2) were an employee of a Humana staff-model HMO when you provided the services that would qualify you as a class member; or 3) are a hospital or facility. (There are other exclusions listed at the end of Section I.A of the settlement notice, but they do not appear to apply to psychologists.)

2. How do I submit a claim to the settlement fund?

The deadline for submitting claims is January 13, 2007.

You can submit a claim by mail or online. For online claims, go to the Human Provider website, fill out and submit the claim form online.

To submit your claim by mail, print out the claim form going to the pddocs website or by going to the settlement website above. You can also use the claim form you may have received in the mail with a settlement notice. Fill out the form and mail it to the address listed at the end of the form. Mailed claims must be postmarked by the January 13th deadline.

The process for both is relatively straightforward and very similar to the process for the CIGNA settlement in 2005. You need to:

  • Provide basic identifying information such as your name, contact information and Humana Provider Number, if applicable;

  • Make a good faith estimate of the volume of claims that you submitted to Humana between Jan. 1, 1990 and September 15, 2006. (Please note that the time period for estimating your claims volume is one month longer than the time period that applies to determining eligibility for filing a settlement claim, which ends on August 16, 2006 – see answer 1 above.) Instead of an exact number, you simply select one of the following ranges:

$0 – 25,000
$25,001 to $100,000
$100,001 to $250,000
$250,001 to $500,000
$500,001 to $1 million
Over $1 million

If you did not submit claims to Humana, but only to other defendants, select the zero to $25,000 range; and

  • Certify under penalty of perjury your representations about eligibility and your good faith estimate of your claims volume.

  • Sign and date the form. (For online claims, your electronic submission acts as your signature.)

Provider Groups or Organizations. If you are submitting claims on behalf of a provider group or organization, you will also need to provide information about the other providers for whom you are a submitting a claim. The settlement notice states that healthcare provider groups and organizations may submit a single claim form on behalf of all of their providers. Alternatively, you may submit individual claims, using amounts billed to Humana under your own individual social security number (and not billed through any group tax identification number).

If you choose to file a single claim for your group/organization, you will have to fill out Section II of the claim form, which requests information about each provider on whose behalf you are submitting a claim (name, social security number or tax ID number, and whether they are still in your group/ organization). The claim may be certified by a single authorized member of the group or organization.

Contributions. You may notice that the settlement gives the various health care professionals in the class the option to contribute their settlement share to their professional association. Psychologists may elect to contribute half or all of their settlement share to the American Psychological Association Practice Organization to continue its advocacy efforts that support professional psychology.

3. What if I did not submit the claims for covered patient services to Humana (or other defendants); instead, my patients submitted the claims?

Effect on eligibility. To be eligible to for the settlement fund, it does not matter whether you or your patients submitted the claims for covered services to Humana (or the other defendants). All that matters for eligibility purposes is that you performed covered services for subscribers of Humana or the other defendants between January 1, 1990 and August 16, 2006.

Effect on estimate of claims volume. When estimating your Humana claims volume, you should only include claims that you submitted to Humana, and not claims submitted by patients. If your patients submitted all claims, you would select the $0–25,000 range as your ‘estimated total claims.’ (See the next question and answer for additional information.)


4. How will the settlement fund be divided among claimants?

After the court subtracts its award of attorneys’ fees from the $3.5 million total fund, the settlement administrator will divide the remainder of the settlement fund among those providers who submit timely claims.

The shares will be weighted and points will be assigned based on the estimated claims submitted to Humana, according to the following formula:

Estimated total claims you submitted to Humana: Points Share of Settlement
Jan 1, 1990 to Sep 15, 2006
$0 – 25,000 1 Base amount
$25,001 to $100,000 2 Base amount x 2
$100,001 to $250,000 3 Base amount x 3
$250,001 to $500,000 4 Base amount x 4
$500,001 to $1 million 6 Base amount x 6
Over $1 million 8 Base amount x 8

After the claims deadline, the settlement administrator will determine the “base amount” by dividing the settlement fund by the number of points submitted by all claimants. The funds will then be allocated as listed in the right column of the chart above. For example, a psychologist whose claims to Humana were in the $25,001 to $100,000 range will get a share twice as big as one who had less than $25,000 in claims.

The size of the base amount depends on how many class members submit claims and how large those claims are. As noted above, we expect the base amount to be smaller than the $212 base amount in the CIGNA settlement. If the court gives final approval to the settlement and no appeals are filed (see question 7 below), the settlement administrator should mail settlement checks in early April 2007.

5. Why is the settlement fund available to psychologists who only provided services to patients insured by other defendant companies besides Humana?

An unusual provision of the settlement in this case is that class members are eligible to submit claims even if they submitted no claims to the settling company — in this case, Humana. They need only have submitted claims to the other defendants. The reason is that the core allegation of the case is that all of the defendant companies conspired together to reduce and delay payment to providers. For example, Dr. Smith, an Aetna provider, has a claim that Humana’s role in the conspiracy helped Aetna to reduce its payment to Dr. Smith. Thus, to settle such conspiracy claims, Humana must compensate the health care professionals who were reimbursed by the other defendants (because the conspiracy allegedly reduced reimbursement from the other defendant managed care companies to their providers). However, because the settlement formula is weighted based on claims to Humana, the non-Humana providers will only be entitled to the smallest size share, i.e., the base amount.

OTHER QUESTIONS ABOUT THE SETTLEMENT AND LITIGATION

6. What are the policy changes in the settlement?

This Q & A focuses on the monetary part of the settlement because eligible psychologists have limited time to submit their claims. The policy changes, however, may have a broader impact on psychology. The following is a brief overview of those changes, which are similar to what CIGNA agreed to in its settlement. We will provide more details in the future.

A major policy-related component of the settlement is that Humana will use its Web site to make various transactions with psychologists easier and faster, while also making its policies and procedures more transparent. Other policy improvements include:

  • Changing the way Humana defines and determines the critical question of whether treatment is “medically necessary,” to give greater deference to the judgment of individual psychologists and APA. For example, “Medical necessity” will be redefined to consider the perspective of a “provider exercising prudent clinical judgment.”

  • Changes to prompt payment policies such as developing a system for paying interest on electronically filed claims that are not paid within 15 days, and giving notice to the psychologist in 15 days if the company needs additional information to process the claim.

  • Prompt updating of provider panel listings. This addresses the “phantom panel” problem whereby consumers find that psychologists in the provider listing are no longer on the panel.

  • Appointment of a psychologist to Humana’s national provider advisory panel. Having such representation gives psychology a voice in the process of developing and implementing company policies.

  • Limitations on the company’s ability to recoup past overpayments to psychologists.

  • Enhanced mechanisms for resolving disputes with the company over medical necessity and billing practices.

These policy changes are available to psychologists in the settlement class who do business with the company now and for the next several years. However, Humana may deny these benefits to psychologists who choose to exclude themselves from the settlement, as discussed in Question [8] below.

7. What is the APA Practice Organization’s relation to the settlement?

The APA Practice Organization became involved in the litigation and the settlement negotiations with Humana (and CIGNA) in order to press the unique concerns of psychology. Although it is not a plaintiff in the case, the APA Practice Organization is a signatory to the Humana settlement (as it was with the CIGNA settlement). Being a signatory allows us to enforce certain settlement provisions on behalf of members, and to post the settlement documents on APA practice.

While the Practice Organization is not a plaintiff in this litigation, we have followed the model of our prior legal actions against managed care companies and have a state psychological association as a party to the litigation. In this Miami-based litigation, the Florida Psychological Association is our state association plaintiff, and the Practice Organization coordinates closely with FPA.

8. Are class members allowed to exclude themselves from the settlement?

Class members have until October 30, 2006 to request exclusion from the settlement class (also known as “opting out.”) The concept is that since class members do not volunteer to be in the class, they should have the option to get out of the settlement if they think the downside outweighs the benefits.

In exchange for receiving the monetary and policy benefits of the settlement, class members must release, that is, give up, certain claims they may have against the company. If you believe you have significant claims against Humana that would be worth the time and expense of litigating separately, the downside of giving up those separate claims might outweigh the benefits of accepting the settlement payout instead. If so, you may wish to consult with a private attorney with appropriate expertise about whether you should exclude yourself from the settlement.

9. What happens next with the settlement and how will I learn about future developments in this case?

In mid-September, Humana put out notice of the settlement by various means, in an attempt to reach as many members of the class as reasonably possible. As we did with the CIGNA settlement, the Practice Organization will also be trying to notify and remind as many members/psychologists as possible in order to maximize psychologist participation in the settlement.

During a "fairness hearing" on December 1, a federal court gave final approval to the nationwide class action lawsuit settlement by Humana. Even though the court gave final approval, that decision could be appealed. Such a development would delay payment and other implementation of the settlement. (The similar CIGNA settlement received final approval during the “fairness hearing” and was not appealed.)

The APA Practice Organization will disseminate information about further case developments on APA practice and in the PracticeUpdate e-newsletter from the APA Practice Organization.


10. What should I do if I still have questions about the settlement, including how to access the available funds?

If you have questions, please contact Alan Nessman of the APA Practice Organization Office of Legal & Regulatory Affairs by e-mail or (202) 336-5886. You can also direct questions to the settlement administrator at 1-800-420-2913.


Please Note: This question-and-answer document is not intended to provide legal advice and the APA Practice Organization is not able to provide legal advice to individual members. If you seek legal advice about the impact of this settlement, you should consult a private attorney with appropriate experience.