TENNESSEE MEDICAL ASSOCIATION FILES LAWSUIT VS HEALTH INSURERS (NATIONAL IMPLICATIONS)

TMA files lawsuit vs. health insurers Says companies' policies imperil patients' well-being

NASHVILLE - Tennessee's largest physician's organization sued the state's four biggest health insurers Thursday, alleging their managed-care practices threaten patients' health.

The Tennessee Medical Association's class-action lawsuits filed in state court name Aetna Inc., BlueCross BlueShield of Tennessee, CIGNA HealthCare and United HealthCare.

The physicians allege that because of the "extraordinary unequal bargaining positions" between the medical association and the insurance companies, the association's 6,600 members are forced into entering one-sided contracts that infringe on the doctor-patient relationship and threaten the continuity of care.

The association says the four companies compose 70 percent of the HMO market in Tennessee and insure nearly 2.4 million people in managed-care plans across the state.

The TMA lawsuits do not seek monetary damages; they ask that the court stop "these wrongful and financially punitive practices."

Physicians' groups in New York and South Carolina have filed similar lawsuits this year. A federal lawsuit against major health-care companies is pending in Florida by 600,000 doctors who claim they are routinely shortchanged on reimbursement claims through "institutionalized underpayments."

"Under the guise of 'managed care,' insurance companies have adopted practices and policies, sometimes secret, which serve to allow the insurance companies to avoid their obligation to pay for care provided to patients," TMA President Dr. David K. Garriott said in a prepared statement.

The lawsuits seek to stop a number of business practices that the Tennessee Medical Association alleges delay, deny or reduce payments to physicians.

For example, they claim the insurance companies "bundle" several physician services together to lower reimbursements and "downcode" doctors' claims to make it appear the doctor performed a simpler procedure, so they can pay less.

deny higher reimbursements for complicated medical cases in which doctors spend extra time and resources.

use computer software programs to automatically deny payment to physicians identified as "high utilizers."

Ron Harr, a spokesman for BlueCross BlueShield, said he had not seen the lawsuit and could not comment in detail, but he called it "shortsighted."

"We do everything we can do to keep health insurance affordable," he said. "The TMA should spend as much energy figuring out how to make services affordable as they are on increasing their reimbursements."

BlueCross pays physicians' claims three times faster than physicians submit them, Harr said. He also said Tennessee physicians receive a 25 percent higher reimbursement rate per capita than the national average.

Representatives of United, Aetna and CIGNA said they had not seen the lawsuits and declined comment.

Dr. Mickey McAdoo, president-elect of the Tennessee Medical Association, said the association and its individual members have been bringing their concerns to the insurance companies almost daily, but to no avail.

He said TMA's problems with the companies come as physicians struggle with low reimbursements under the TennCare program for the state's poor and uninsurable. The lawsuits are not related to TennCare, McAdoo said, except they are a sign of physicians' continuing frustration with managed care.

In addition to the TMA lawsuits, four individual physician lawsuits were filed against the companies, seeking monetary damages on the same grounds. They cite claims not paid in full, interest due for untimely or slow payments and payments never made but rightfully due.

"If these lawsuits progress, there may be some injunctive relief that extends across other states, creating an opening of eyes and a changing of attitudes," he said.

I would love to see the HMO's get their just rewards for what it has done to this state. I would love to see them shut down. I do not consider this a frivolous lawsuit by any means, as Tenn Care has brought great damage upon the state and our doctors. It has made Tennessee Health Care System like that of Canada. The way it was done was what can best described as extortion & blackmail against both the doctors and the taxpayers. Maybe Civil Court will accomplish what our corrupt leaders can not. ENDING TENN CARE!

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