Florida physicians are clearly on the offensive in their ongoing tangle with HMOs. Recently they've initiated five lawsuits and a complaint with the Florida Department of Insurance.
The 16,000-member, Tallahassee, Fla.-based Florida Medical Association recently filed a complaint with the state Insurance Department, charging that Blue Cross and Blue Shield of Florida is violating a state statute by engaging in unfair competition and unfair or deceptive acts. At issue is a contract amendment that participating physicians were asked to sign and return by Sept. 1; those who didn't will face termination from the Blues PPO network effective Oct. 1.
"In the past, many providers were afraid that if they initiated litigation to collect on claims, the managed-care organizations would exercise their right to terminate without cause," says Gary Davis, a health law attorney in the Miami office of McDermott, Will & Emery. "I think the provider mindset has changed. If the cost of suing is losing business, (they're) no longer afraid of that consequence."
The current Blues battle dates back to March, when the insurer first asked physicians to sign and return a contract amendment that calls for an expansion of the Blues preferred provider organization, known as the Preferred Patient Care program. Almost 30,000 Florida physicians participate in the program, and it provides care to 1.2 million Floridians.
Under the expansion, physicians will be required to accept PPC patients from all Blues plans but be paid at Florida Blue reimbursement rates. Previously, if a Florida physician saw a PPC patient from Ohio, the physician was reimbursed at Ohio rates. Now, the physician will be reimbursed at Florida rates.
FMA general counsel John Knight says the association is not concerned about the new reimbursement plan but rather how the contract change was implemented. "What we've objected to are the strong-arm tactics by Blue Cross to force physicians to sign an amendment," he says. "We would have no problem if the program were voluntary, but it's mandatory. Blue Cross' actions in attempting to compel physicians to sign the amendment form, or else face termination from Blue Cross' PPC network, clearly constitute coercion and intimidation."
Blues spokesman Rick Curran says that 24,000 of the 29,000 participating physicians have already signed the agreement, and termination letters were mailed to the other 5,000, effective Oct. 1. The expanded PPC program will give plan members national access to healthcare services when they travel outside of their state and "has no material impact on Florida physicians," Curran says.
In early July, the FMA filed a complaint similar to the one it filed against Blue Cross and Blue Shield with the Department of Insurance concerning Blue Bell, Penn.-based Aetna U.S. Healthcare's all-product contract. The association filed two other complaints within the last year, one against United Health Care of Florida and another against Prudential Health Care Plan for downcoding claims.
Another physician organization, the 3,300-member, Jacksonville, Fla.-based
Florida Physicians Association, has filed five suits in Florida's district courts against insurers in the past year.
Targets of the suits are Roseland, N.J.-based Prudential HealthCare and Miami-based AvMed, for denial of claims; Humana Health Plan of Florida, for reimbursing at rates other than what its contract promised; and United Health Care of Florida and HIP Health Plan of Florida, for downcoding claims. All action is pending.
Don Weidner, FPA general counsel and executive director, acknowledges that it is not cheap to pursue so much legal action, but Florida physicians are beyond fed up. "Physicians have been battling these problems with managed care for so long, and now their frustration level has reached its zenith," he said.