Insurance companies have consistently underpaid
physicians over the last decade. After trying to find cooperative
ways to resolve the problem, a class-action lawsuits on behalf
of physicians has begun to produce some results, but much more
is needed. While it is unfortunate that physicians had to resort
to lawsuits to be treated fairly, we hope these outcomes will
motivate other health plans to be more ethical and fair in their
relationships with physicians and patients.
Below are summaries of just a few of the
news briefs at MedicoUnlimited,
a health consulting firm. Click on their section of healthcare
news. You can also find on that site news on the actions taken
against physician groups trying to negotiate fairer contracts
with health insurance plans. The cases, in my view, illustrate
how physician's hands are tied in their attempts to negotiate
in a non-adversarial way.
What do these lawsuits mean for patients
It means that physicians have a legitimate complaint that is
leading to courts finding for their claim or insurance companies
It also means that physicians are restricted
in ways to gain fair relationship with insurance companies in
It illustrates that physicians are routinely
punished and restricted for attempting to negotiate fair contracts.
While these are steps in the right direction,
my guess is that insurance companies will use these and the push
to be fair in their relationship with physicians as a justification
for premium rate increases for patients. Don't buy it. Premiums
have continued to increase, while physician rates have declined.
Physician payment is not the cause of rate increase in our insurance.
(We will have another article on what some of the causes are
and more recommendations for action.)
A class action suit was filed in 1999 against 6 of the nation's
largest health insurers for violations of the Racketeering Influenced
and Corrupt Organizations Act (RCO) for their payment methods
to physicians and is just now in 2004 at the point of resolution.
Health plans named in the suit are:
Aetna, Anthem, Humana, Cigna, PacificCare Health Systems, UnitedHealth
Group, and WellPoint Health Networks.
May, 2003 (Modern Healthcare) Aetna
agreed to pay $470 million dollars in a class action suit filed
by physicians in 1999. The suit, representing 700,000 physicians,
and filed my medical associations in Texas and California, claimed
that Aetna was systematically reducing payments and interfering
in patient care. As part of the settlement, Aetna is required
* pay $100 million to physicians
* establish a $20 million dollar charitable foundation to find
ways to improve medical care
* pay approximately $50 million in attorneys' fees
* establish an advisory panel that includes doctors to work on
* change billing methods
Aetna also agreed to pay $4 million dollars
to 147,000 dentists, plus another $1 million to the American
Dental Association's charitable foundation because of routinely
delaying or reducing payments for dental claims. In addition,
Aetna promised to:
* clarify the details of its claims process
* reduce paperwork and increase computerization
Aetna paid $75 million in attorney fees
during the second quarter of 2003.
Additional note on Aetna:
In October 2004, Aetna and Cigna both
are included as defendants in a suit that alleges a scheme to
fraudulently market, sell and administer insurance products through
employee benefit plans and to steer business to a broker in exchange
for kickbacks. They are part of the
Cigna settled their part in the lawsuit
after an initial offer the year before was rejected. They agreed
to pay $85 million.
In separate cases:
Blue Cross Blue Shield:
The Connecticut Medical Society included
Blue Cross and blue Shield Association and its member plans in
a class action suit for depriving physicians of millions of dollars
due them. The suit alleged that BCBS forced physicians into unfavorable
contracts, used computer programs to routinely deny or delay
payments and interfered in patient care. Although they and the
other defendants who had not settled tried to get the case appealed
in regard to its class-action status, the court ruled against
Humana has agreed to pay 1,900 physicians
in 3 states in the Cincinnati area $100 million over 3 years
($20 million, $15 million and $10 million) as a result of a case
filed agains four health insurers. It will be a 30% increase
in some of their reimbursement rates. The suit claimed that Humana
had conspired for years to use illegal and anti-competitive practices
to supress reimbursements to physicians. After the 3 years, a
committee will oversee Humana's talks with physicians to make
sure that there are not anti-competitive activities. Humana also
will pay $6 million in attorney fees.
As always, I welcome your constructive
comments and suggestions about the material on this website and
how we can all be most effective in co-creating the kind of healthcare
system we all want. E-mail me at firstname.lastname@example.org
© Dawn Lipthrott,
Ethical Health Partnerships, 2005 www.ethicalhealthpartnerships.org
(May be copied and distributed
as long as this identifying information is retained on copies.)
WHAT YOU CAN DO TO HELP
C0-CREATE MORE ETHICAL PARTNERSHIPS: Check
back because we will be adding action opportunities.
YOUR INSURANCE COMPANY:
these cases represent progress, they are specific to the case
and not nationwide.
letters and e-mail, encourage your insurance company (and others,
if you are willing) to adopt not only fairer rates, but other
areas of reform that have come out of the lawsuits:
create better methods of prompt payment instead of intentional
b) Reduce paperwork and increased computerization
* reduce administrative costs
* simplify and speed up
the payment process
create advisory boards that include practicing physicians and
patients to create fairer relationships and practices that consider the good
make reimbursement rates and policies more transparent for both
physicians and patients
past actions. insurance companies are likely to attempt to pass
on the costs to consumers while using the payments to physicians
as an justification of their premium increases.
letter or e-mail, make sure you let your insurance company know
that you as a patient know they have increased premiums even
with inadequate reimbursement to physicians.* A significant cause
of the increase is their profits and their administrative costs
which have gone from an average of $86 per year patient to $360
per patient. Encourage them to look at ways to reduce administrative
costs rather than compromise their relationships with patients
and physicians. Another way they can reduce cost is to better
educate their members and the public on preventing disease, and
offer incentives for members who do.
for a response to your letter. If the company does not respond,
follow up with another letter or e-mail.
of getting discouraged by insurance company responses attempts
to brush you off, or failure to respond, use it as an indication
of the need to hold all of our healthcare partners and ourselves
responsible for more ethical health partnerships.
YOUR STATE INSURANCE REGULATORY OFFICE:
Tell your insurance regulator or comptroller that you want better
regulation of reimbursement rates and practices toward physicians.
as an opportunity to also let them know you want better regulation
of your own health insurance premium rates and malpractice insurance
them to enter into more ethical healthcare partnership with physicians
and patients. (we will be doing more in this area later)
PURCHASE INSURANCE (as a company or individual):
companies for information on their rates of reimbursement . .
.how much their rates to physicians have increased or decreased
yearly over the past 5 years. Suggest that they break it down
into primary care, general surgery, OB/GYN.
for the yearly increase in premium rates for a person in your
age group over the past 5 years. Be sure to state that you want
the information from the point of view if a person of your age,
non-smoker, normal weight, no significant medical history, had
purchased health insurance 5 years ago.
you may get first year buy-in rates over 5 years, which is not
an indicator of what your rate increases will be over time as
while it is important to hold insurance companies responsible
for their partnership in our healthcare, they are not all of
the problem. We all contribute and need to address the issues
at multiple levels.
Unlimited news section has interesting information about increase
in premiums compared to the increase in wages of workers.)