Guidance on submitting claims in the Ingenix class action lawsuit settlement
by Legal and Regulatory Affairs Staff
July 28, 2010 — This FAQ answers questions that psychologists may have about United Healthcare’s (United’s) $350 million settlement in the nationwide class action against the company by providers and subscribers (policyholders). Many psychologists received notices in April 2010 regarding the settlement. The case alleged that United and other defendants used United’s faulty Ingenix database to suppress “usual, customary and reasonable” (UCR) rates used for reimbursing out-of-network services.
In essence, the settlement fund compensates psychologists and other providers who were paid less then their billed charges on eligible claims. It also compensates insureds/patients who were under-reimbursed.
Please note: The APA Practice Organization (APAPO) is not able to provide legal advice to individual members, and this FAQ does not constitute legal advice. If you want legal advice about your rights or options under this settlement, you should consult a private attorney with appropriate experience.
Questions about participating in the settlement
What is the deadline for submitting claims?
Am I eligible to file a settlement claim?
What is the simplest way to submit a claim to the Settlement Fund?
How do I submit a claim for Increased Damages?
How will the settlement fund be divided and how much will I recover?
What if I still have questions about the settlement or filing claims?
Question 1: What is the deadline for submitting claims?
Your claim must be postmarked on or before October 5, 2010. Any claims postmarked after that date will not be accepted.
The settlement will not become final until after the Fairness Hearing scheduled for September 13, 2010 (further described in Question 7). We expect, however, that the court will approve the settlement so we do not recommend waiting for final approval because the court might not give that approval until just before the October 5 deadline.
Question 2: Am I eligible to file a settlement claim?
As a psychologist, you are eligible to file a settlement claim if you:
Provided out-of-network services beginning March 15, 1994, through November 29, 2009, to any patient whose health plan was insured or administered by any of the defendant companies: United Healthcare, Metropolitan Life Insurance Company and American Airlines — or to the parents, subsidiaries or affiliates of those companies. United’s major subsidiaries, affiliates, etc are:1
- United Behavioral Health or UBH (part of OptumHealth)
- Oxford Health Plans Inc.
- PacifiCare Health Systems Inc.
- Mid-Atlantic Medical Services Inc. (MAMSI)
- Sierra Health Services.
Billed under an assignment of benefits. If you were paid directly by an insurer, that is a likely indication that you had an assignment; and
Sent the patient an adjusted bill, representing the unpaid amount(s) owed for the out-of-network services provided.
If you received a settlement notice, you are likely to meet at least the first two requirements. The Settlement Administrator sent the notices based on claims information received from United and other defendant companies. Thus, if you received a notice, you should at least consider filing a claim the simplest way, as described in the next question.
Question 3: What is the simplest way to submit a claim to the Settlement Fund?
The simplest way to submit a claim is to rely on your claim history that the defendant companies have given the Settlement Administrator as required by the settlement. The steps are:
Request a copy of your claim history report from the Settlement Administrator.
Fill out information on the claim form and check the box that you want to rely on the Settlement Administrator’s information.
Mail in the claim form, postmarked by October 5, 2010.
Below are detailed instructions for each step:
This simplest claim option (Simplified Claim) will result in the lowest level of compensation based on 50 percent, instead of 70 or 90 percent of your loss, as described in Question 6. The settlement offers higher compensation levels if you can document that you billed patients for the portion of their fees not paid by the defendants, or made efforts to collect these amounts from patients.
A Simplified Claim will cover your claims only for the period from January 1, 2002 through May 28, 2010, which defendants are required to provide to the Settlement Administrator. To include claims from before or after this time frame,2 you will have to submit additional documentation (as described in Question 5).
You need not submit all of your claims at the same time. Thus, you could submit a Simplified Claim for the 2002 to 2010 period now and gather the necessary information to submit claims for earlier or later periods before the October 5 deadline.
1Additional United subsidiaries, affiliates, etc. include: Arnett Health Plans, Definity Health Corp., Fidelity Insurance Group, Fiserv Inc., GenCare Health Systems Inc., Golden Rule Insurance Company, HealthPartners of Arizona Inc., HCT, HealthWise, IBA Health & Life Assurance Co., IBA Self-Funded Group, John Deere Health Care Inc., MetraHealth, Neighborhood Health Partnership, PHP, Student Resources (former student insurance division of MEGA Life and Health), Touchpoint Health Plan Inc., United Medical Resources.
2Those earlier and later periods are: 1) March 15, 1994 through December 31, 2000 and 2) May 29, 2010 until the settlement is finally approved, which should occur after the Fairness Hearing scheduled for September 2010.
Detailed instructions for a simplified claim
Step A: Ask the Settlement Administrator for a copy of your claims history report.
This step will allow you to view your claims history provided by defendants that is the basis for your simplified claim recovery, and to identify any errors or missing claims. It will also help you determine if your settlement check is in the correct amount. This step is not required, but is recommended.
The easiest way to obtain your claims history report is to request it on the Berdon Claims Administration website.3 You will be asked for your “notice number,” which is located on your notice form beneath the return address and bar code on the outer page of the notice. If you do not have that number, write “not available” in the space provided.
Step B: Fill out the Settlement Claim Form
The claim form starts at page 10 of the 15-page settlement notice that many psychologists received. If you did not receive that notice, or if you lost it, you can obtain a form on the Berdon Claims Administration website (PDF, 218 KB).
In filling out the claim form, all you need to do is:
Fill out your provider or provider group information on page 10 and check the appropriate box (for provider or provider group representative.
Check the “I am a provider” box at the start of Section 5 on page 13, as well as the “I choose to file a Simplified Group D claim” box below that in Section 5(a).
Sign and date the Certification at Section 6 on page 15.
Step C: Mail the form, postmarked by October 5, 2010
Mail your claim form to:
United HealthCare Class Action Litigation
c/o Berdon Claims Administration LLC
P.O. Box 15000, Jericho, NY 11853-0001
We recommend sending the form certified and requesting return receipt so you will have proof that it was postmarked on time and received by the Settlement Administrator.
3Alternatively, you can complete and sign the authorization form included on page 15 of the settlement notice that you may have received in the mail. Return the completed and signed authorization form to the Settlement Administrator by mail, fax or e-mail. E-mail; Tel: (800) 443-1073; Fax: (516) 222-0271; Mail: United HealthCare Class Action Litigation, c/o Berdon Claims Administration LLC, P.O. Box 15000, Jericho, NY 11853-0001.
Question 4: How do I submit a claim for increased damages?
You can increase your settlement recovery in two ways through an Increased Damages Claim: (1) by including claims for services not included in the Settlement Administrator’s claims history report (for claims outside of the date range of the report and/or claims within the date range that were not included in the report); or 2) by demonstrating additional efforts to collect from patients in order to be compensated at the 70 percent or 90 percent rate.
Increased Damages Claims require that you submit the documentation described below, in addition to completing the three steps outlined in Question 3. (However, in completing those steps you will not check Box 5(a) for Simplified Claims (Step B, second bullet point.)
Your documentation must show that you billed a defendant for out-of-network services under an assignment of benefits, as described below.
To be eligible for a 50 percent recovery (for claims in addition to those listed in the Settlement Administrator’s claims history report), you must submit copies of any of the following documentation along with your completed and signed claims form:
A claim for out-of-network services provided during the eligible claim period from March 15, 1994 until final approval of the settlement (likely in fall 2010, see Question 7) and submitted to the insurer; or
A cancelled check from the insurer for services provided during the eligible claim period; or
A paper or electronic copy of an explanation of benefits/explanation of payment/remittance advice from the insurer indicating payment was made to you for services provided during the eligible claim period; or
Evidence from your practice management system records or internal accounting records (e.g., accounts receivable or accounts paid records) reflecting you either submitted a claim to the insurer or received payment from the insurer under an assignment for services provided during the eligible claim period; and
Evidence of payment from the patient (if any) during the class period.
To be eligible for a 70 percent recovery, you must submit copies of the following along with your completed and signed claims form:
The above-described documentation (for 50 percent recovery); and
The adjusted bill sent to the patient (for the amount of your fee not paid by a defendant) on or after January 1, 2002; or
Evidence from your practice management system records or internal accounting records that reflects that you sent an adjusted bill to the patient on or after that date.
To be eligible for a 90 percent recovery, you must submit copies of the following along with your completed and signed claims form:
The above-described documentation (for 50 percent recovery); and
Correspondence with or notice to a collection agency or credit agency; or
A payment plan you entered into with a patient; or
Evidence from your practice management system records or internal accounting records that reflects that you submitted the adjusted bill to a collection agency, reported the adjusted bill to a credit agency or entered into a payment plan with the patient.
For Increased Damage Claims, you must also include the requested information described in the chart under Section 5(c) at page 14 of the claims form for each claim:
Date of service;
Patient’s policy ID number;
Original billed amount (your billed charge);
Allowed amount (amount paid by insurer);
Amount paid by the patient (excluding co-pays or deductibles); and
Whether you are seeking recovery at the 50 percent, 70 percent or 90 percent rate.
For claims covered by the Settlement Administrator’s claims history report, some of this information can be found in that report. Additional charts for submitting claims are available on the Berdon Claims Administration website (PDF, 15 KB). While the claim form must be mailed to the Settlement Administrator, you can submit supporting documentation electronically as described at p.9, Paragraph 10 of the settlement notice.
Question 5: How will the settlement fund be divided and how much will I recover?
The $350 million settlement fund will be divided among a large class of providers (including psychologists, physicians, social workers and physical therapists) and an even larger class of subscribers (insureds/patients) who file timely claims with the Settlement Administrator.
Payments to providers will be based on 50 percent, 70 percent or 90 percent of your anticipated Recognized Loss, depending on which category of claim you file (as described in Question 3 and 4). The Recognized Loss is the difference between the amount you billed the defendant insurer for out-of-network services and the amount you were paid, less 20 percent to account for co-pays, coinsurance, or deductibles for which your patient would have been responsible.
If the total amount of claims accepted by the Settlement Administrator is less than or equal to the Settlement Fund, all claimants will receive their full Recognized Loss. If the total is greater than the Settlement Fund, claimants will receive a percentage of their Recognized Loss based on a pro rata allocation.4 The settlement is designed is to pay out essentially all of the Settlement Fund to class members, except for attorneys’ fees and the costs of administering the Settlement Fund.
Whether the total claims will exceed the Settlement Fund depends on the number and size of settlement claims submitted by all other eligible class members. Thus, it is not possible to predict whether you will receive the full 50, 70 or 90% of your Recognized Loss (as described above), or a smaller pro-rata share.
Because of the large volume of claims anticipated, there will likely be at least several months between the October filing deadline and the mailing of settlement checks.
Question 6: What if I still have questions about the settlement or filing claims?
American Psychological Association Practice Organization (APAPO) members can contact the Legal & Regulatory Affairs Department with questions at (800) 374-2723, ext. 5886 or send an e-mail.
You can also submit questions directly to the Settlement Administrator:
United HealthCare Class Action Litigation
c/o Berdon Claims Administration LLC
P.O. Box 15000
Jericho, NY 11853-0001
4If the Settlement Fund is not big enough to pay all claims, a pro rata allocation means that each claimant will receive the same percentage share of the settlement, and the same proportion relative to other claimants, but in smaller amounts.
General questions about the litigation
Question 7: What happens next with the settlement?
The Court has scheduled a “fairness hearing” to be held on September 13, 2010, at the federal court in Manhattan, NY, to determine whether the settlement is fair to the class as a whole. If the Court determines that it is fair (which we expect it will), and gives final approval to the settlement, the approval may still be appealed, which would delay implementation of the settlement including allocation of the cash settlement fund.
If there are significant changes with the settlement that impact psychologists submitting settlement claims, the APA Practice Organization will notify members through this e-newsletter.
Question 8: Will there be there be other Ingenix settlements?
The APA Practice Organization is collaborating with the state psychological associations in California and New Jersey on three ongoing nationwide class actions similar to the United suit. These cases, filed in the summer of 2009, allege that WellPoint/Anthem BCBS, CIGNA and Aetna used United’s Ingenix database to suppress out-of-network reimbursement to psychologists.
The APA Practice Organization will inform members if there are settlements in these cases.
Question 9: What policy changes result from the United settlement?
Consistent with the terms of a separate settlement reached with the New York Attorney General, the settlement requires United and the other defendants to change their reimbursement practices for out-of-network services. The defendants have agreed to stop using the Ingenix database for calculating out-of-network reimbursement rates (after a transition period) and to contribute $50 million toward funding and implementation of a new database that will be independently established and operated by a consortium of New York State university-level schools of public health. United will also coordinate with the consortium to create the Healthcare Information Transparency website that will allow the public to access information about the range of provider charges, by geographical region, contained in the new database.
We understand, however, that some large insurers may be moving away from basing out-of-network reimbursement on usual and customary provider charges, relying instead on factors such as Medicare rates.