Frequently Asked Questions
What
is the nature of the litigation?
The complaint filed by the ADA, James Swanson, D.D.S.,
Michael Dayoub, D.D.S., and John Milgram, D.D.S.
alleges that, between 1995 and 2003, Aetna
improperly denied, delayed and/or reduced payment to dentists
by engaging in several types of allegedly improper conduct,
including bundling, downcoding and rejecting claims for
covered services. The complaint also alleges that Aetna
used improper guidelines and criteria to determine UCR
amounts for dentists' own geographic areas. The complaint
claims that this conduct violated federal and state law.
The ADA’s case against Aetna is one significant
component of the ADA's litigation on behalf
of dentists against other insurance carriers,
pending in the United States District Court
for the Southern District of Florida. The ADA’s settlement
with Aetna does not extend to these other carriers.
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Who does this proposed settlement apply to?
If you are or have been a dentist who has provided covered
services to any person enrolled in or covered by a plan
offered and administered by Aetna during the period beginning
August 15, 1995 through April 23, 2004, you are a potential
class member, and this proposed settlement applies to you.
This proposed settlement applies to both participating
and non-participating dentists.
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Under the proposed settlement, what policies has Aetna
agreed to implement with respect to its billing
practices for the benefit of dentistry?
Aetna has agreed to implement many new policies, as well
as revise many of its billing practices, including:
- Aetna will no longer automatically downcode
or bundle claims for covered services, as
of the date when the court formally approves
the proposed settlement agreement.
- Aetna will provide a fee schedule, upon written
request, to a dentist who has a valid contract
with Aetna.
- Aetna has agreed to disclose its claim reimbursement
methods and rules concerning downcoding
and bundling within 180 days of the court
formally approving the agreement. Aetna has
agreed to post its disclosure on its web
site at www.aetna.com, and update such disclosure, as
necessary, at least once every 180 days.
- No later than
six months after the court formally approves
the settlement agreement, Aetna will disclose
on its web site a standard pre-certification list and
update such list as needed.
- Upon receiving a written appeal by a dentist
appealing a reduction in requested payment
based on Aetna’s
determination that the requested payment
exceeds UCR, Aetna will undertake a case-by-case
review of the appealed case. This review will consider,
among other things, the complexity of the applicable
procedure and the provider’s
geographic location. In conjunction with
the appeal, Aetna will identify any external
database used in making the UCR determination, and will
provide to the dentist a summary of the factors known
by Aetna to have been used in the development of that
database.
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will the Explanation of Benefits (EOB) look like?
In any EOB sent to an individual who is enrolled in or
covered by a plan offered or administered by
Aetna that includes a UCR determination, Aetna
will provide the following statement: "Your
plan provides benefits for covered services at the prevailing
charge level, as determined by Aetna pursuant to the terms
of your contract. Aetna’s
determination of the prevailing charge does
not suggest that your provider’s fee is not reasonable
or proper."
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Is Aetna providing any monetary payment to class members?
Yes. Aetna has agreed to set up a settlement fund containing
$5 million, $1 million of which will be paid directly to
the ADA Foundation, which is the charitable arm of the
ADA. The remaining $4 million will be available for payment
to class members. The amount per class member will be added
to this document when it becomes available.
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How do class members receive their payments?
In order to collect payment from the settlement fund,
class members must fill out a Proof of Claim
Form. This form must either be typed or printed,
and must also be notarized by a notary public. The Proof
of Claim Form is posted on the ADA web site at www.ada.org/goto/aetnasettlement,
and on the class counsel web site at www.pomerantzlaw.com.
If class members prefer voice mail to request
faxed copies of this form, members of the ADA
should call the member toll free number, ext. 2396, to
request these copies. All others should call (312) 440-2396.
All completed and signed forms must be mailed to the Settlement
Administrator, who administers the Settlement Fund, and
postmarked by July 2, 2004. If a class member does not
mail his/her signed and notarized claim form by the postmark
date, the class member will not receive any share of the
settlement fund. Instead, the class member’s share
will be automatically donated to the ADA Foundation. Class
members should mail their signed and notarized form directly
to:
Managed Care Litigation
c/o Berdon Claims Administration LLC
P.O. Box 9014
Jericho, NY 11753-8914
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Can class members expressly donate their share of the
settlement fund to the ADA Foundation instead?
Yes.
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How can class members donate their
share of the settlement fund to the ADA Foundation?
Two methods exist for class members to donate their share
of the settlement fund to the ADA Foundation. First, if
the class member does not fill out a Proof of Claim Form
(or submits the form after the postmark date), the class
member’s payment from the settlement fund will be
automatically donated to the ADA Foundation. Second, a
class member may be able to take a tax deduction for the
donation by filling out a Proof of Claim Form, and specifically
checking off a box on the form, expressly directing the
class member’s payment to the ADA Foundation. The
class member should keep a copy of the signed Proof of
Claim Form for his/her records. However, this is not tax
advice, and class members should first consult with their
tax advisors. Again, all completed forms must be mailed
directly to:
Managed Care Litigation
c/o Berdon Claims Administration LLC
P.O. Box 9014
Jericho, NY 11753-8914
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How will the ADA Foundation use the donated payments
from class members?
The ADA Foundation will use funds received from the settlement
for the following purposes:
- Promoting dental hygiene among traditionally
underserved populations, including but
not limited to addressing racial, economic,
and geographic disparities.
- Promoting children’s dental health,
including but not limited to fluoridation
and education.
- Promoting evidence-based dentistry, including
but not limited to research into and dissemination
of information regarding pharmacology, dental
disease, and standards of care.
- Redressing the shortage of dentists, including
but not limited to increasing auxiliary
capacities and licensing by credential.
- Supporting research that links dental disease
with systemic disease.
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How can class members obtain copies of documents related
to the proposed settlement?
Detailed information regarding the proposed settlement,
including forms and other documents, is posted
on both the ADA and class counsel web sites.
The ADA web site address is www.ada.org/goto/aetnasettlement,
and the class counsel web site address is www.pomerantzlaw.com.
If class members prefer voice mail to request
faxed copies of these forms, or to request
a callback from ADA staff, members of the ADA
should call the member toll free number, ext.
2396. All others should call 312-440-2396.
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What should I do if Aetna
does not change the things noted in the
answer to the third question above?
The proposed settlement agreement allows for arbitration
to resolve disputes with respect to Aetna’s compliance
with the agreement.
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I still have additional questions. Where can I go
for more help?
Detailed information regarding the proposed settlement,
including forms and other documents is located
on the ADA’s
web site at www.ada.org/goto/aetnasettlement and
the class counsel’s web site at www.pomerantzlaw.com.
If you would like voice mail to request a callback
from ADA staff, ADA members should call the
member toll free number, ext. 2396. All others
should call 312-440-2396. Finally, you may e-mail the ADA
directly with any questions at AetnaSettlement@ada.org.
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