Issue Background


Out of Network Legislation
MSNJ continues to fight against legislation that would unfairly reduce physician payments and contract negotiation footing. MSNJ is a part of a coalition of providers who favor disclosure and transparency from providers and payers, but oppose fee schedules and mandatory arbitration. MSNJ continues to advocate for its non-binding dispute resolution process. See recent press coverage here

Out of Network Legislation

The Assembly Financial Institutions and Insurance Committee is gearing up to tackle health insurance matters this fall. MSNJ is meeting with committee members and legislative leaders to advise them of our position on the issue.  See our memo HERE.

Read the Mental Health Association's Managed Care Network Adequacy Report here.

Read MSNJ's letter regarding narrow networks.

MSNJ continues to oppose legislation that would limit charges and payments and impact network contracting.  View television coverage.

The Assembly Financial Institutions and Insurance Committee held its second hearing on out of network charges. The Committee aims to hear from stakeholders before considering legislation.  MSNJ has met with the Chairman, members and staff of the committee regarding this issue.  Please find press coverage of the hearings here:

Updated: Hospitals Chief Spars with Insurers Business Groups Over Health Care Charges During Assembly Committee Testimony

Advocates Call for Changes to Out-Of-Network Medical Billing at Trenton Hearing

Out of Network Press Coverage:

A 10-minute doctor's visit and a $1315 bill - Asbury Park Press

Sentinel Project:

Sentinel Project Hopes to Help Newly Insured Get What They’ve Paid for

More information on Sentinel Project

Prior Authorization/Step Therapy:

MSNJ supports measures that ease prior authorization, like this bill:

MSNJ also supports a bill that would reduce step therapy requirements. Find our letter HERE.

Guide to Aetna/UCR Class Action Settlement--Actions that Must be Taken by Physicians

  • Deadline to Opt-Out is February 26, 2014
  • Deadline to file a claim is March 28 , 2014
  • Request Information from Aetna AS SOON AS POSSIBLE


Physicians who treated Aetna patients out of network between June 3, 2003 and August 3, 2013 have received a notice in the mail concerning the settlement of a class action lawsuit filed by MSNJ and other state medical societies. This lawsuit was filed to address Aetna’s use of the Ingenix data base to determine usual customary and reasonable fees. The Ingenix data base was previously discredited in a lawsuits against its owner, United Health Group, and in an enforcement action by the New York Attorney General. Those matters were settled on the condition that UHG dismantle Ingenix and fund an independent, transparent data base to replace it. Since Aetna used the Ingenix data base a suit was filed to recover the difference between the amounts Aetna paid and what should have been paid if the Ingenix data base were accurate.

Aetna has agreed to settle the case by establishing funds available to physicians who treated patients out of network and to their patients, both of whom were not adequately paid.

The subscriber (patient) settlement fund is $40 million. The provider (physician) settlement fund is $20 million. There is also a general settlement fund in the amount of $60 million which may be available to either to the subscriber or provider pool of applicants depending on how the funds are exhausted.

The final settlement hearing will take place on March 18, but physicians must take actions before that date to opt-out and pursue claims outside of the settlement. While physicians have until March 28 to file a claim it will not be possible to put together an Option 2 claim without extensive work which should be undertaken, or at least evaluated, as soon as possible.

Physicians must decide:

  • Whether to file a claim to recover from the physician fund;
  • Whether to opt-out of the settlement agreement; or
  • Whether to do nothing.

Each decision will have consequences.

If you file a claim, the amount you receive will depend on the filing option (explained below) that you select and the number of other applicants to the fund. In addition, you will release and discharge any and all claims through August 30, 2013.

If you wish to pursue out of network claims against Aetna on your own, or if you have pending lawsuits or efforts to collect out of network fees against Aetna for a time period up to and including August 3, 2013, you must opt-out of the agreement to preserve the right to pursue those claims. If you do not opt-out you will be releasing and discharging those claims.

Physicians are urged to review the release (Page 3 of the notice) carefully and consult counsel if you are not clear on the consequences.

If you do nothing, you will not receive any money from the settlement fund and you will release and discharge these out of network claims against Aetna through August 30, 2013.

If you do not know whether it is worthwhile to file a claim or to opt-out you should request information from Aetna as soon as possible. To do so, complete the part of the form that requests information and mail it as soon as possible. (See page 15 of the notice and question 25 in the FAQ.) Aetna will provide the information that it has, but this information may not be comprehensive. You should also check your own records. Requesting this information may help you to decide whether to file a claim under option 1 (a streamlined process) or under option 2 (a claims-based option that will require documentation).

Evaluate whether to file a streamlined claim or a documented claim:

Option 1:

Option 1 is a streamlined process and does not require the documentation necessary to support an Option 2 claim. However, the amount of money that is available under Option 1 is limited. Physicians using Option 1 will be limited to an annual amount between $20 and $40 per years under Option 1. (See page 4 of the notice and questions 20 & 43 in the FAQ.) The provider claim form begins on page 11 of the notice.

Option 2:

Options requires documentation, but could yield a higher distribution. (See questions 35 & 36 in the FAQ.) Under this option you may recover 3 to 5% of the allowed amount on claims that were only partially paid. To file under Option 2 the amount at issue must exceed $750 for an individual or $1,000 for a group. If your Option 1 claim is defective and not cured it will be treated as an Option 1 claim. (See questions 21 & 44 in the FAQ.)

Note: The notice and claim form is for both subscribers (patients) and providers. Be sure to follow the process for providers. If you were also an Aetna subscriber you may file a claim as a patient. (See question 24 in the FAQ.)

Physicians are urged to carefully read the notice and information on the settlement web site.

MSNJ and other state societies also made “associational” claims seeking to be compensating for the efforts undertaken by the societies to assist members to recover adequate out of network fees. The associational claims have been dismissed and are currently being appealed.


January 16, 2014




Horizon Responds to MSNJ Concerns about New Network Requirements 

On May 29, Horizon announced in a letter to its network physicians that they would need to be board certified and have full privileges at one of its network hospitals by April 2013. Needless to say, these requirements were simply not achievable by many physicians who had long-served Horizon as network providers. MSNJ’s CEO, Larry Downs, immediately reached out to Horizon’s top management about our concerns over the new network requirements. Horizon agreed to consider our position, and later offered to speak with each MSNJ member, individually, about the impact of its newly announced network requirements.

We are pleased that Horizon responded to our concerns by grandfathering current PPO providers from the board certification requirement. Horizon also established a number of exceptions to the requirement to have privileges at a network hospital. These include: physicians with valid Continuation of Care forms on file; anesthesiologists and pain management physicians who have privileges with at least one free-standing ambulatory surgical center; and a number of specialists, including: allergists, dermatologists, physiatrists, and ophthalmologists.

MSNJ appreciates Horizon’s prompt response and accommodations to the significant concerns of our members who have been long-standing network participants.

Physicians who may be affected by Horizon’s new network requirements are urged to read Horizon’s letter explaining the changes to its originally announced policy.


Largest Healthcare Fraud Settlement in U.S. History

Last week, the Department of Justice announced the largest healthcare fraud settlement in U.S. history. GlaxoSmithKline (GSK) agreed to pay $3 billion to resolve a number of criminal and civil lawsuits alleging: unlawful promotion--off-label uses; failure to report certain safety data; and false price reporting activity. The settlement resolves liability for off-label promotion of Paxil, Wellbutrin, Advair, Lamictal and Zofran, and for alleged kick-backs to physicians for prescribing Imitrex, Lotronex, Flovent and Valtrex. It also resolves alleged underpayments of rebates to Medicaid.

GSK entered into a five-year corporate integrity agreement which requires notice to physicians of the terms of the settlement and establishes a speaker monitoring program. Visit the DOJ website for details on the settlement agreements.


Governor Christie Vetoes Health Insurance Exchange (HIX) Legislation

Citing the unresolved health care issues before the U.S. Supreme Court, Governor Christie vetoed the HIX legislation yesterday. Read the press release and the Governor's veto message. MSNJ looks forward to working with the Governor and Legislature to help craft an exchange that will provide more options for New Jersey residents to obtain affordable healthcare insurance.


ICD-10 Delay Proposed in Unique Health Plan Identifier Rule

CMS published a proposed rule on April 9 that formally calls for delaying the implementation date of ICD-10 for one year, from October 1, 2013 to October 1, 2014. Read more.


MSNJ Leads Rule-making that Directly Impacts Physicians

Two state regulatory proposals will have a direct impact on virtually every member of MSNJ and physicians practicing in New Jersey. DOBI’s re-proposed regulation on managed care contracts is the culmination of seven years of MSNJ work, beginning with the passage of the managed care reform law in 2006 and the settlement of national class-action lawsuits with the major healthcare insurers over the past decade. One element of managed care reform is regulations that will legally bind healthcare insurers to fair contract principles with participating physicians. MSNJ has tirelessly spearheaded this initiative, meeting with representatives at the highest level of both DOBI and the Governor’s Office. This has caused the re-proposal to be released for comments.

Similarly, DOBI re-proposed regulations governing the personal injury protection (PIP) program in New Jersey when MSNJ expressed concerns over the comprehensive rule proposal. This has already resulted in the removal of the proposed workers compensation managed care organization (WCMCO) network. Read more.


MSNJ Comments on Health Insurance Exchange (HIX) Legislation

Last week, MSNJ submitted comments to the Senate Commerce Committee, regarding the Health Insurance Exchange (HIX) legislation, bill, A-2171 (Conaway, D – Burlington). MSNJ supports active purchasing, meaning the Board of the Exchange would scrutinize plans to determine if they should be offered through the HIX. MSNJ also advocates that practicing physicians be included in HIX implementation. We recommend that a separate, clinical advisory committee be created and given direct input into the board’s certification of health plans.