Two Florida doctors and the Broward County Medical Association have sued Humana Health Plan of Florida, accusing the insurer of low and slow payments and rewarding physicians who refer only to capitated physicians.
The suits, filed Jan. 18 in Broward County, accuse the Louisville, Ky.-based insurer of automatically downcoding claims, delaying payment and directing patients to capitated physicians within the Humana network rather than to other qualified physicians also in the network. Downcoding is the practice of paying the rate for a less involved patient visit even if the visit was lengthy or involved a complicated illness. Florida's prompt payment law requires HMOs to pay undisputed and clean claims within 35 days.
Pamela Gadinsky, spokeswoman for Humana, said the company hadn't been served with the lawsuit at Modern Physician press time and couldn't comment on the specific allegations. Humana is the third-largest insurer in the state, with more than 648,000 enrollees.
In general, she says, Humana reviews claims and requests a one-page fax of the medical record for billing.
Gadinsky adds that Humana's procedure isn't much different than what HCFA soon will require from providers. She also says that the HMO is working with the Florida Medical Association to provide educational seminars on how to properly code claims.
Although the suits seek damages for the individual physicians--Harold Landa, M.D., and Seth Cutler, M.D.--the medical association joined the suits to try to stop Humana from downcoding all physician claims, says attorney Michael Ryan.
Ryan says he didn't know how much the two physicians are owed. The two suits seek payment of previously downcoded claims, from around October 1998 to January 1999, as well as interest that would have accrued. The suit asks for damages in excess of $15,000 plus attorney fees.
"When a physician objects to the downcoding, Humana then purports to provide a medical records review by an outside company," the suit alleges. "As a result of Humana's general business practice, the physician incurs additional unreimbursed expenses and delays in obtaining any reimbursement."
Additionally, in the second lawsuit, Cutler and the medical association are suing over giving primary-care doctors incentives not to refer patients to Cutler, an ophthalmologist. The primary-care physicians can share in profits by referring patients to capitated physicians, the suit alleges, because the more money the HMO saves the higher any shared profits will be. Cutler was noncapitated.
"As a general business practice, primary-care physicians with the Humana network have been encouraged by Humana to discourage patient choice in specialists," the suit alleges. "This occurs even though Humana represents to the patient and specialist physicians that other specialists are available for care and treatment."
The doctors also contend the practice results in deceptive advertising because enrollees are told they have a choice in providers.
According to the suit, Cutler complained several times to Humana representatives about the lack of referrals. Cutler's contract with Humana was canceled effective Jan. 31. No reason was given in the suit for the cancellation.
The cases were the latest in a series of lawsuits filed by Florida physicians and physician organizations.
In early July, the Florida Medical Association filed a complaint against UnitedHealthcare of Florida and Prudential Health Care Plan for downcoding claims.
Another physician organization, the 3,300-member Jacksonville-based Florida Physicians Association, has filed five suits against insurers in the past year.
Targets of the suits are Prudential HealthCare and AvMed, for denial of claims; Humana, for reimbursing at rates other than what its contract promised; and UnitedHealthcare of Florida and HIP Health Plan of Florida, for downcoding claims.
In September, Florida's Department of Insurance warned HMOs to stop automatically downcoding medical claims. The state last fall also warned health plans to watch how they pay providers and fined three HMOs for slow and low payments to emergency room doctors.
The Department of Insurance last year announced a joint audit of the state's 16 Medicaid and 35 commercial HMOs (See September, page 18.)
Although the insurance commissioner's actions have tried to address downcoding as a whole, Ryan says it's necessary to address more specifically the problems involving Humana.
"This is a large HMO," he says. "We're talking about doctors who receive $20 or $16 for office visits that are automatically downcoded."