Humana Settlement Information

The Humana Settlement

NEW! (3/17/2010) Humana Agrees to Continue Many of the Settlement Terms after Settlement Agreement Officially Terminates

The Settlement Agreement with Humana officially terminated on October 19, 2009. Nonetheless, in the interest of continuing to enhance its relationships with physicians, Humana has voluntarily agreed to maintain in effect many of the most important terms of the Settlement Agreement. In reaching this decision, Humana sought input from the Physicians Advocacy Institute, Inc. (PAI) and Humana executives met with attorneys for several of the medical societies represented on PAI’s Board prior to finalizing its business plans.

Humana has agreed to maintain the following Settlement provisions in effect:

  • 90 days' advance written notice prior to implementing material adverse changes, including fee schedule reductions
  • Application of the clinical definition of medical necessity as spelled out verbatim in the Settlement Agreement
  • Application of the coding rules required by the Settlement Agreement
  • 18 month limitation on seeking overpayment recovery
  • Posting significant coding edits and the list of code combinations not appropriately reported with modifiers 25 and 59 on its Provider Website

The following Settlement Agreement terms will no longer remain in effect:

  • Although Humana will continue to pay interest as on late-paid claims as required by state law, it will no longer pay interest on late-paid self-funded claims.
  • Except as required by state law, Humana will no longer be bound to recognize assignment of benefits.
  • Although Humana has no current plans to revise its fee schedules more than once a year, it will not agree to be bound by this limit.
  • Although Humana will create a new Physicians’ Advisory Committee, the Committee established by the Settlement Agreement will be disbanded.

HISTORY OF THE SETTLEMENT On September 27, 2006 counsel for approximately 900,000 physicians and Humana , Inc. and Humana Health Plan, Inc. ("Humana") announced that they had received a final order settling a national class action lawsuit in federal court for the Southern District of Florida before U.S. District Judge Federico Moreno as well as multiple state court actions filed against the company. Humana is the fifth national health plan named as a defendant in the Managed Care Litigation in Florida to settle with physicians. The agreement includes both a monetary settlement and substantial commitments by Humana to institute a significant number of business practice changes that will benefit physicians.

This agreement includes industry-leading improvements to physician-related business practices. The cornerstone of these business practices is Humana's agreement to apply generally accepted medical standards and specific claims guidelines. Additionally, Humana has committed to increase transparency in paying claims and has agreed to an enforcement mechanism to help ensure compliance with the terms of the settlement. The agreement will also streamline communication between physicians and Humana, reduce administrative complexity in the claims payment system and help to improve the quality of the health care system in general.

The establishment of a Physicians’ Advisory Committee (PAC) of practicing physicians was one initiative contained in an agreement between Humana and representatives of thousands of physicians that settled a national class-action lawsuit. View the list of members of the Humana PAC.

Expiration date for this settlement agreement is 10/19/2009.

Humana Compliance Dispute Information

Critical to the success of this settlement is the enforcement process, which will be facilitated by Deborah Winegard. In her role as the Compliance Dispute Facilitator, Ms. Winegard will oversee the compliance dispute resolution mechanism that is designed to address physician complaints regarding Humana's compliance with the terms of the settlement agreement.

The compliance dispute process is triggered by filing a brief dispute form describing how Humana has violated the terms of the settlement agreement. Documentation which illustrates the violation should be included with the form. Filing a compliance dispute involves no cost to physicians or their practices. For further information about the compliance dispute process or a copy of the dispute form, click on the appropriate links below.

Information about the Settlement

Humana Settlement Agreement

Humana Settlement Exhibits

Signatory Medical Societies

  1. Original Signatory Societies
  2. Additional Signatory Societies
  3. Joinder Form