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How the Aetna Settlement Agreement helps the physician practice

The Aetna Settlement Agreement (“Settlement”) benefits physicians in a number of ways including reducing adminis- trative burdens and simplifying claims submission and processing. Physicians and their staff can register referrals, pre-certify procedures, submit claims for covered services, check plan member eligibility for covered services, and check the status of claims for covered services at Aetna’s Web site www.aetna.com.

Contracts provided by Aetna to physicians in its provider network must conform to the Settlement. Physicians should review all future Aetna contracts to make sure that they include a clear written representation that the proposed contract does not waive or conflict with any of the business practice initiatives Aetna has agreed to implement under the Settlement. An example of such language would be:

Aetna represents that nothing in this contract waives or conflicts with any of the business practice initia- tives it has agreed to undertake pursuant to the Settlement Agreement dated as of May 21, 2003, in the In Re: Managed Care Litigation, Master File No.: 00-1334-MD-MORENO.

Under the Settlement, certain business practices are prohib- ited, such as those reflected in “gag” clauses, “all products” clauses, and restrictions on stop-loss coverage from other insurers. However, it must be underscored that physicians can waive the protections that are contained in the Settlement. If the physician receives a contract with terms that are inconsistent with the Settlement and signs the contract then the Settlement protections may be waived. Physicians should consult with their attorney before agreeing to waive any protections provided in the Settlement. Physicians should consider asking Aetna to separately identify and explain in writing each provision in the physician’s contract that is inconsistent with the Settlement and that could result in a waiver by the physi- cian of the protections provided to the physician in the Settlement.

Physicians should review all contracts from every payer before signing any contract to understand the implications of the contract on their practices. The American Medical Association (AMA) provides several useful tools to educate physicians on managed care contracts. The AMA Model Managed Care Contract contains sample contract language designed to assist physicians in avoiding common contracting pitfalls. The “15 Questions to Ask Before Signing a Managed Care Contract” flyer is designed to complement the AMA Model Managed Care Contract and provides a roadmap to help physicians evaluate whether to sign a managed care contract. This material is available on the AMA Web site at www.ama-assn.org/go/psa.

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 that they are receiving avail- able protections.

A summary of the “key” business practices mandated in the Settlement can be found on the reverse side of this flyer. This flyer does not summarize or identify all of the protections provided in the Settlement. Physicians are encouraged to download the Settlement from www.hmosettlements.com or obtain additional information, including compliance dispute processes, from the AMA Web site at www.ama-assn.org/go/settlements. Physicians may consider filing a compliance dispute if prohibited clauses are contained in a contract submitted by Aetna.

For additional information, go to the AMA Private Sector Advocacy Web site at www.ama-assn.org/go/psa. You may also visit the American Urological Association’s Web site at www.auanet.org.

This informational flyer was developed through a cooperative effort between the American Medical Association and the American Urological Association.

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