When American physicians are upset about their fees, they don't go on strike — they go to court.
Thanks to a recent court ruling, 600 000 physicians have been given the right to sue some of the nation's largest HMOs for fraud and racketeering. The ruling allows the doctors, who are supported by 5 state medical societies, to press a class-action suit claiming that they have been systematically defrauded by HMOs that arbitrarily and routinely cut fees.
The amount of the claim has not yet been determined, but lawyers say hundreds of millions of dollars have been swallowed by HMOs that “downcode” doctors' billings, retroactively deny claims for medically necessary services and offer bonuses to claims reviewers who delay or deny claims. For instance, lawyers allege that a “25-minute visit of moderate/high complexity with an established patient” is commonly downcoded to a 15-minute visit of low/moderate complexity, which saves the HMO $50 or more.
The suit identifies 9 companies, including Aetna and Humana Health Plan, as coconspirators. It was originally filed by the California Medical Association, and the action was subsequently joined by medical societies in Florida, Texas, Georgia and Louisiana. Any doctor who accepted HMO patients after 1990 can participate.
“America's physicians … are determined to restore sanity and fair play to what has become a very disturbing industry,” says Archie Lamb, a lawyer for the doctors. “Call it cheating. That's what it is.”
Karen Ignani, president of the American Association of Health Plans, which represents the nation's HMOs, called the charges “trumped up” and doubts that 600 000 physicians qualify for the class action. — Milan Korcok, Florida