Physicians Advocacy Institute
The Physicians Advocacy Institute’s mission is to advance fair and transparent payment policies and contractual practices by payers and others in order to sustain the profession of medicine for the benefit of patients.
The Physicians Advocacy Institute, Inc., (PAI) is a not-for-profit 501(c) (6) advocacy organization established in 2006 with funds from the Multi-District Litigation (MDL) class action settlements against major national for-profit health insurers. The PAI's primary mission is two-fold: to guarantee compliance with the settlements by these health insurers; and to develop projects and tools for the future that guarantee the viability of physicians' medical practices and the ability of physicians to deliver quality patient care. Specifically, the final settlement between plaintiffs and the Prudential Insurance Company of America indicates that settlement funds will be used "to address issues relating to abuses of managed care," through assuring compliance and "identifying and addressing future health plan practices that burden the ability of Class Members to be paid fairly for their services."
The class action lawsuit known as Managed Care Litigation (MDL No. 1334) was originally filed in 2000 and was a combination of several cases filed around the country on behalf of physicians against for-profit health insurance companies. The basic allegations were that these health insurance companies, among other complaints, systematically denied, delayed and/or reduced payment to physicians who had delivered services to covered patients. Seven settlements with national health insurers have been reached to date: Aetna; CIGNA; Prudential; Anthem/WellPoint; HealthNet; and Humana. On April 27, 2007, several Blue Cross Blue Shield plans and plaintiffs announced settlements.
While the settlements have resulted in retrospective relief to physicians, the real value of the settlements for physicians was the prospective relief provided. The settlements offered protection to physicians (class members) going forward, including a compliance dispute procedure and a billing dispute procedure, which allowed physicians to have a process for resolving disputes with the defendant health insurers over issues such as downcoding, bundling, refusal to recognize modifiers, prompt payment, and a number of other protections.
The plaintiff state and county medical associations wanted to continue the momentum to restore fairness in managed care business practices gained through the lawsuits and resulting settlements, and the Physicians Advocacy Institute, Inc., was formed. The PAI believes it is imperative that health insurers continue to voluntarily adhere to the terms of the settlements to which they agreed, even though the settlements have expired. To continue liaison activities with health insurers, the PAI has a Physician Advocacy Liaison Committee comprised of the General Counsels of the PAI Board-member states.
The PAI intends to undertake specific projects to educate physicians about various managed care initiatives to enable physicians to be better informed and to understand how various health plan initiatives, like pay for performance and “rating” of physicians, will impact the day-to-day care that physicians provide their patients. PAI intends to be an advocate for physicians in all areas of health insurers’ managed care business practices so physicians and state and county medical associations are prepared to respond in knowledgeable, timely and appropriate ways. In this spirit, the PAI has developed MDEdgeTM, a health claims data warehouse that will allow physicians to determine if their claims for payment have been paid accurately by health insurers. For more information about MDEdge and how to enroll, please visit www.MDEdge.com.
For more information about the PAI, please contact: Mary Jo Malone, Vice President and CEO, PAI, [email protected].
Donald P. "Rocky" Wilcox, JD
Texas Medical Association