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October 01, 2002
600,000 Doctors Going to Trial With HMOs
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Last week, U.S. District Judge Federico Moreno certified a class representing up to 600,000 physicians in a case against many of the country's largest health maintenance organizations.
Doctors included in the class have worked as HMO providers since 1990 for Aetna, United Healthcare, CIGNA, Coventry, Wellpoint, Humana Health Plan Inc., Pacificare Health Systems Inc. and Anthem Blue Cross Blue Shield. All are named as defendants.
As Moreno described it in his ruling, the doctors will try to prove that the HMOs conspired to "systematically obstruct, reduce, delay and deny payments and reimbursements to health care providers."
The Sun-Sentinel newspaper of Fort Lauderdale, Fla., reports that Moreno set a trial date of May 19. Cases filed throughout the country have been consolidated in Miami federal court.
While Moreno did not rule on the merits of the doctors' suit, the Sun-Sentinel reports that he found evidence to back up their position. "The provider plaintiffs have done more than just allege a common scheme," the judge wrote. "They have demonstrated facts which support its existence."
Filings in the case show the HMOs' extensive use of programs that "downcode and bundle claims, delay and wrongfully deny payments," the judge wrote. In downcoding, the newspaper explains, a health care service's difficulty is disputed, and the reimbursement is lowered accordingly; in bundling, a doctor is compensated for a single service when two or more services were rendered.
Despite giving class-action certification to the doctors, Moreno rejected doing the same for about 145 million HMO patients, who say their coverage plans promised them optimal care and then defrauded them by failing to provide it. The subscribers, Moreno wrote, could not show a common pattern of activity requiring class-action treatment.
To view the Sun-Sentinel article, click here.
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