The Aetna settlement agreement applies to all dentists who have provided covered services to any person enrolled in or covered by a plan offered and administered by Aetna during the period beginning Aug. 15, 1995, through the date on which the agreement receives preliminary court approval. Accordingly, this settlement applies to both participating and nonparticipating dentists.

Under the proposed settlement, Aetna has agreed to implement numerous changes in connection with its billing practices and reimbursement procedures that are unparalleled in the insurance industry, including the following:

– Aetna no longer will automatically downcode or bundle claims for covered services, as of the date when the court formally approves the proposed settlement agreement.

– Aetna will provide a fee schedule, on written request, to a dentist who has a valid contract with Aetna.

– No later than six months after the court formally approves the settlement agreement, Aetna will disclose on its Web site a standard precertification list and update such list as needed.

– Upon receiving a written appeal by a dentist appealing a reduction in requested payment based on Aetna’s determination that the requested payment exceeds the UCR fee, Aetna will undertake a case-by-case review of the appealed case. This review will consider, among other things, the complexity of the applicable procedure and the provider’s geographic location. In conjunction with the appeal, Aetna will identify any external database used in making the UCR determination, and will provide to the dentist a summary of the factors known by Aetna to have been used in the development of that database.

– In any Explanation of Benefits sent to an individual who is enrolled in or covered by a plan offered or administered by Aetna that includes a UCR determination, Aetna will provide the following statement: "Your plan provides benefits for covered services at the prevailing charge level, as determined by Aetna pursuant to the terms of your contract. Aetna’s determination of the prevailing charge does not suggest that your provider’s fee is not reasonable or proper."

In addition, Aetna has agreed to set up a settlement fund containing $5 million, $1 million of which will be paid directly to the ADA Foundation. The remaining $4 million will be available for payment to class members. To collect payment from the settlement fund, class members must fill out a Proof of Claim Form. This form must be either typed or printed, and also must be notarized by a notary public. The Proof of Claim Form will be mailed within 30 days of the preliminary approval of the settlement agreement by the court.

All completed and signed forms must be mailed to the Settlement Administrator, who administers the Settlement Fund. Both the postmark date and the address of the Settlement Administrator will be included on the Proof of Claim Form. If a class member does not mail his or her signed and notarized claim form by the postmark date, the class member will not receive any share of the settlement fund.

However, class members can opt to donate their share of the settlement fund to the ADA Foundation. Two methods exist to accomplish this. First, if the class member does not fill out a Proof of Claim Form (or submits the form after the postmark date), the class member’s payment from the settlement fund automatically will be donated to the ADA Foundation.

Second, a class member may be able to take a tax deduction for the donation by filling out a Proof of Claim Form, and specifically checking off a box on the form, expressly directing the class member’s payment to the ADA Foundation. The class member should keep a copy of the signed Proof of Claim Form for his or her records. However, this is not tax advice, and class members should first consult with their tax advisers. Again, all completed forms must be mailed directly to the Settlement Administrator.

The ADA Foundation will use funds received from the settlement for the following purposes:

– promoting dental health among traditionally under-served populations, including but not limited to addressing racial, economic and geographic disparities;

– promoting children’s dental health, including but not limited to fluoridation and education;

– promoting evidence-based dentistry, including but not limited to research into and dissemination of information regarding pharmacology, dental disease and standards of care;

– redressing the shortage of dentists, including but not limited to increasing auxiliary capacities and licensing by credential;

– supporting research that explores links between dental disease and systemic disease.

When available, the Proof of Claim Form will be posted on the ADA Web site at "www.ada.org/goto/aetnasettlement" and on the class counsel Web site at "www.pomerantzlaw.com". Detailed information regarding the proposed settlement, including other forms and documents, also will be located on the ADA and class counsel Web sites as such information becomes available. If class members prefer voice mail to request faxed copies of any forms, or to request a callback from ADA staff, Association members should call the ADA member toll-free number, Ext. 2396. All others should call 1-312-440-2396. Finally, class members may e-mail the ADA directly with any questions at "AetnaSettlement{at}ada.org".

The ADA’s case against Aetna is one significant component of the Association’s litigation on behalf of dentists against other insurance carriers, pending in the U.S. District Court for the Southern District of Florida. While the ADA’s settlement agreement with Aetna does not extend to these other carriers, the ADA hopes that the agreement generally will become a model for the industry. Many Association members have contacted the ADA to say that they are very pleased with the settlement.

View larger version (125K): [in this window] [in a new window]   Mr. Sfikas is ADA chief counsel and an adjunct professor of law at Loyola University of Chicago School of Law. He has lectured and written on legal issues and is a fellow of the American College of Trial Lawyers. Address reprint requests to Mr. Sfikas at the ADA, 211 E. Chicago Ave., Chicago, Ill. 60611.