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How the Humana Inc. Settlement Agreement helps the physician practice

Summary of “key” Humana Settlement provisions

Coding rules

Humana shall comply with most AMA Current Procedural Terminology (CPT®)* codes, guidelines and conventions.

Humana will not automatically downcode or reduce the code level of any evaluation and management (E/M) CPT code for covered services, except to reassign a new patient to an estab- lished patient based on AMA CPT codes, guidelines and conventions.

If a bill contains a CPT code for the performance of an E/M service appended with a CPT modifier 25 and a CPT code for performance of a non-E/M service, both codes shall be recog- nized and separately eligible for payment, unless Humana disclosed on its physician Web site that the code combination was not appropriately reported under its policy.

If a bill appropriately contains a CPT code for the performance of a preventive medicine E/M service and a CPT code for the performance of a problem-focused E/M service appended with a CPT modifier 25, both codes will be recognized and eligible for payment.

*CPT is a registered trademark of the American Medical Association.

The Humana Inc. (“Humana”) Settlement Agreement ( S e t t l e m e n t ) p r o v i d e s f o r g r e a t e r t r a n s p a r e n c y i n H u m a n a claims processing and payment practices. Through this Settlement, Humana implemented a series of initiatives to improve its relationships with physicians, including but not limited to: reduced pre-certification requirements; greater notice of policy and procedure changes; reduced claim resubmissions; and improved accuracy of information about eligibility of plan members. Humana, via the Internet or clearinghouses, also has given physicians access to register referrals, pre-certify proce- dures, submit claims for covered services, check plan member eligibility for covered services and check the status of claims for covered services. s

In addition, Humana has committed to disclose certain business practices and provide contracts to physicians in its provider network that conform to the Settlement.

Physicians should review all future Humana contracts to ensure they do not contain any provisions that are inconsis- tent with any of the business practice initiatives that Humana has agreed to implement under the Settlement. An example of such language is:

Humana represents that nothing in this contract is inconsistent with any of the business practice initiatives it has agreed to undertake pursuant to the Settlement Agreement dated as of October 17, 2005, in the In Re: Managed Care Litigation, MDL No.: 00-1334-MD- MORENO.

Under the Settlement, certain business practices are prohibited or restricted, such as: the inclusion of “gag” clauses in provider contracts as well as “all products” clauses; ability of physicians to obtain stop-loss coverage from other insurers; and the use of pharmacy risk pools.

Physicians should note that the Settlement provides that if state law offers more protection than the Settlement, then state law applies. Physicians need to be aware of relevant state laws and regulations, particularly in the area of prompt payment of claims, to ensure they receive all available protections.

Physicians should review all contracts from every payer to understand the implications of the contract on their practices before signing any contract. The American Medical Asso- ciation (AMA) Model Managed Care Contract contains sample contract language designed to assist physicians in avoiding common contracting pitfalls. Visit www.ama-assn.org/go/psa where this material is available to AMA members at no cost.

This handout does not summarize or identify all of the protec- tions provided in the Settlement. If you believe Humana is not complying with any of the Settlement provisions listed below, you may initiate a compliance dispute by filing a compliance claim form (available at www.hmosettlements.com). Visit the AMA Web site at www.ama-assn.org/go/settlements for more information concerning the compliance dispute process, or contact the Humana compliance dispute facilitator, Carol Scheele, at cscheele@ncmedsoc.org or (919) 833-3836. The compliance dispute claim process is available to you at no cost and may be an effective way to ensure that Humana honors its commitments under the Settlement.

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