Managed Care Settlements

Key Aspects of Anthem/Wellpoint Settlement

In addition to the monetary component of the settlement, physicians and WellPoint have agreed to new levels of transparency and communication as well as a renewed commitment concerning business practices through a number of initiatives. In the agreement, WellPoint has agreed to, among other things:

• A definition of medical necessity that ensures that patients are entitled to receive medically necessary care as determined by a physician exercising clinically prudent judgment in accordance with generally accepted standards of medical practice;
• Use of clinical guidelines that are based on credible scientific evidence published in peer reviewed medical literature (taking into account Physician Specialty Society recommendations, the views of Physicians practicing in the relevant clinical areas, and other relevant factors) when making medical necessity determinations;
• Provide physicians with access to an independent medical necessity external review process;
• Establish an independent external review board for resolving disputes with physicians concerning many common billing disputes;
• Pay for the cost of recommended vaccines and injectibles and for the administration of such vaccines and injectibles;
• Not automatically reduce the intensity coding of evaluation and management codes billed for covered services;
• Ensure the payment of valid clean claims within fifteen (15) days for electronically-submitted claims and thirty (30) days for paper claims;
• Provide fee schedules via electronic communication;
• Establish a compliance dispute resolution mechanism to address disputes regarding WellPoint's compliance with the agreement;
• Establish a physician advisory committee; and
• Provide ninety (90) days notice of changes in practices and policies and annual changes to fee schedules.

Links:

• Key Aspects of Anthem/Wellpoint settlement
• Step-By-Step Guide for filing a Compliance Dispute
• Anthem/Wellpoint Compliance Dispute Form
• Anthem/Wellpoint Joinder Agreement [doc]