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Proposed Settlement in Class Action Involving Payment for Non-contracted Emergency Physician Services
PINECREST, FL, MARCH 25, 2009 - A hearing will be held in the United States District Court, Southern District of
Florida, on April 15th, 2009 in Miami, Florida, to consider the fairness, reasonableness, and adequacy of a proposed settlement
in the case of Weinberger, et. al. v Aetna Health, Inc., Case no. 1:06-cv-20249-Moreno/Torres. The proposed settlement addresses
a class action lawsuit brought against Aetna Health, Inc. for their interpretation of usual and customary charges (U&C) as 125%
of the Medicare fee schedule. Under the current proposed settlement, Aetna will pay non-contracted emergency physicians at 239% of
the Medicare fee schedule for services provided between June 3rd, 2003 and December 15th, 2008.
Florida Statutes prohibit emergency physicians from balance billing HMO beneficiaries for emergency services. Florida Statute 641.513
addresses payments by HMOs to non-contracted emergency providers by stating that reimbursement should be the lesser of: 1) The provider's
charge; 2) The usual and customary (U&C) provider charge in the community; or 3) A fee mutually agreed upon by the HMO and the provider
within 60 days after submittal of a claim. Since passage of 641.513 in the 1990s, some HMOs have attempted to apply their own definition for U&C.
"Recent court action in California and potential legislative action in Texas have placed a spotlight on the practice of balance billing in
emergency medicine," said Jeffrey Bettinger, MD, FACEP, Managing Member, BSA Healthcare. "Settlement of this class action may have profound
effects regarding definition of U&C charges in states, such as Florida, that either have or are considering balance billing prohibitions
for emergency services."
To learn more about how this settlement may affect emergency physician reimbursement, please call Jeffrey Bettinger, MD, Managing Member of BSA
Healthcare, at 305-860-3098 or email Dr. Bettinger at jbettinger@bsanda.com.
About BSA Healthcare
BSA Healthcare is a physician-owned healthcare consulting firm that helps hospitals, academic medical centers,
private medical practices, and outpatient facilities improve quality, financial performance, operations,
organizational structure, and strategic direction. Visit www.bsahealthcare.com or call 1-888-568-4993.
BSA Healthcare Services
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