Doctors Press Battle Against Insurers
The California Medical Assn. renewed allegations that many of the largest insurance companies conspired to defraud doctors in a lawsuit that was expected to be filed Monday against the managed-care companies.
Medical societies in Texas and Georgia also joined the suit, which is part of a broader legal assault on managed care.
The amended suit marks the California doctors’ second attempt to justify claims that insurers violated federal anti-racketeering laws. A federal judge in Miami rejected the conspiracy allegation on March 2, but gave the doctors until Monday to further substantiate the claim and resubmit it.
The suit is among two dozen filed against managed-care firms around the country that have been consolidated in Miami for pretrial purposes. The suits, most of which represent patients and not doctors, seek class-action status.
The amended suit claims eight insurance companies functioned as an “enterprise” under the federal Racketeer Influenced and Corrupt Organizations Act. It said the companies relied on the same guidelines and systems, provided by outside vendors, to process and review claims.
The suit alleges the systems were manipulated to wrongly alter claims or deny them.
“We feel it is imperative that physicians be able to take care of patients the way they need to,” said Dr. Joy Maxey, president of the Medical Assn. of Georgia. “We render service, we render care, and we don’t receive payment for what we did.”
Named as defendants are Aetna Inc., including its Prudential unit; Cigna Corp.; Coventry Health Care; Foundation Health System, including its Health Net unit; Humana Inc.; PacifiCare; United Health Care; and WellPoint Health Networks, the parent of Blue Cross.
The suit originally filed by the California doctors named only Blue Cross, PacifiCare and Foundation.
Aetna issued a statement saying that although it hadn’t seen the suit, “as a general matter, many of these suits are similar and we continue to believe that they are without merit.”
The suit asserts the industry’s trade group, American Assn. of Health Plans, and several vendors, including Milliman & Robertson and HBOC McKesson, conspired with the insurers, but doesn’t name them as defendants. The companies had no comment.
The American Assn. of Health Plans said there are better ways to resolve disputes than through costly litigation. “The only thing we know for certain about suits is that consumers end up paying higher health-care costs,” spokeswoman Susan Pisano said.
U.S. District Judge Federico A. Moreno on March 2 let stand claims that the insurance companies had broken their contracts with doctors and enriched themselves at physicians’ expense.
The doctors aren’t seeking monetary damages. They want a court order that would regulate specific practices under managed care, such as patient referrals and diagnostic tests. They also want changes in the way doctors are compensated under certain managed-care plans.
“We have to get the health plans to the table,” said Jack Lewin, chief executive of the California Medical Assn. “The health plans have been exerting undue influence in a . . . marketplace that prevents us from providing the best care to patients.”
The American Medical Assn., although not a party in the case, has said it supports the lawsuit.
