Providers' suits against the nation's insurers gained momentum last month, but the expanding legal challenge moved California medical leaders to assure Aetna that they weren't gunning for the nation's biggest health plan.
On March 26, the California Medical Association refiled a class-action lawsuit, adding the Medical Association of Georgia and the Texas Medical Association as plaintiffs, along with 20 individual physicians. Within hours of filing the amended complaint against some of the nation's biggest insurers, however, the CMA was scrambling to eliminate the perception it was suing Aetna.
In fact, the CMA is suing Blue Cross/Wellpoint, Foundation/Health Net and PacifiCare. The Texas Medical Association is suing Cigna and Humana, while the Medical Association of Georgia is suing Aetna, Cigna and Coventry Health Care.
The suit, filed in Miami in the U.S. Southern District on behalf of almost 80,000 physicians, is the largest provider case against insurers.
In December, the CMA and Aetna agreed on a working document containing a set of blueprint principles to address physician concerns. Among other provisos, Aetna agreed to drop the all-products clause and pay actuarially sound capitation rates. Aetna and CMA officials continue to meet to discuss how to work together.
In a CMA press release the day after refiling its suit, CEO Jack Lewin, M.D., took the unusual step of assuring everyone the Aetna agreement was still intact and that the doctors had a good working relationship with the insurer.
Aetna officials declined to comment on the agreement, its status or whether the suits cast a bad light on the company.
CMA sued Health Net and PacifiCare because they are the largest for-profit HMOs in the state and the ones with whom there have been the most problems, says spokesperson Peter Warren.
Initially only the CMA was a plaintiff, but the Georgia and Texas groups joined the amended suit after the initial complaint was dismissed March 3.
"This is our Alamo," says TMA President Jim Rohack, M.D. "This is our last chance to halt these HMOs' predatory and destructive business practices that cannot be remedied through the well-worn paths to the Legislature, Congress and regulatory agencies."
Most insurers declined to comment on the amended complaint. Officials with the American Association of Health Plans say the suit is without merit, that lawsuits will drive up the cost of healthcare and that a recent survey shows physicians don't support litigation against health plans.
The amended complaint alleges that the health plans:
- denied or delayed payments,
- forced physicians into contracts that don't cover the cost of patient care,
- utilized financial criteria, not medical criteria, to deny claims and
- provided financial incentives to claim reviewers who met arbitrary denial quotas.
Over the past 18 months, dozens of cases have been filed against the nation's major insurers. A team of attorneys, including Richard Scruggs and Archie Lamb, have accused the health insurers of everything from fraud to deceit to extortion. Scruggs and his team successfully sued the tobacco industry.
All the cases will be heard in the Miami courtroom of Federal District Judge Frederico Moreno, who was assigned the cases in October. He divided the cases into provider and patient tracks.
On March 2, Moreno dismissed the racketeering claims filed against the health plans. However, he left the door open to hearing those allegations if the plaintiffs reargued their points, which is what plaintiffs' attorneys attempted to do in their March 26 filing. In his order, Moreno wrote the providers' attorneys would have to prove an enterprise existed in order to have grounds for an anti-racketeering suit.
Among the elements plaintiffs say constitute an enterprise is the movement of high-ranking health plan officials between plans. The attorneys used Aetna's recent hire of William Popik, M.D., as chief medical officer as an indication of the conspiracy because Popik used to work for Cigna and other health plans.
Arguments on motions to dismiss the cases are expected late this month or in early May.