New York doctors sue managed care insurers, claim illegal practices.Six of the largest managed-care insurance carriers in New York New York, state, United States New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of "harm both patients and physicians by systematically engaging in illegal practices," allege six separate lawsuits. They were filed in the New York County Supreme Court against Aetna, Inc.; Cigna Healthcare; Empire Blue Cross/Blue Shield; Excellus, Inc.; Oxford Health Plans, Inc.; and United HealthCare of New York. The suits, filed August 15 by the Medical Society of the State of New York (MSSNY MSSNY Medical Society of the State of New York )--a 30,000-member organization of physicians, medical residents, and medical students, located in Lake Success--seek permanent injunctive relief injunctive relief n. a court-ordered act or prohibition against an act or condition which has been requested, and sometimes granted, in a petition to the court for an injunction. . Individual society members also filed suit, seeking monetary damages Monetary damages, in civil law, refers to compensation given to an injured party by a liable party. Monetary damages may be restitution, a penalty, or both. . The legal action is the "culmination of years of intransigence in·tran·si·gent also in·tran·si·geant adj. Refusing to moderate a position, especially an extreme position; uncompromising. [French intransigeant, from Spanish intransigente : by the managed care insurance carriers and the utter disregard for the rights of the patients and physicians," said society president Robert Bonvino of Staten Island Staten Island (1990 pop. 378,977), 59 sq mi (160 sq km), SE N.Y., in New York Bay, SW of Manhattan, forming Richmond co. of New York state and the borough of Staten Island of New York City. . "It is a sad comment on the way these insurance carriers conduct business that we have to go to the court system to force them to live up to their obligations." The suits specifically point to the insurers' "continual, arbitrary" denial of medically necessary care medically necessary care, n the reasonable and appropriate diagnosis, treatment, and follow-up care (including supplies, appliances, and devices) as determined and prescribed by qualified appropriate health care providers in treating any condition, , "capricious" reductions in reimbursement claims, and denial of claims based on "arbitrary guidelines." They claim that the carriers--which control almost half the managed care contracts in New York--fail to provide adequate staffing to handle the volume of claims submitted, and that they provide physicians no information about how claims decisions are made. Other alleged misdeeds include: * failure to pay specialists, claiming they lack a referral when a referral has been submitted * violation of New York statutory provisions regarding payment and interest * delay of reimbursement, forcing physicians and their staffs to expend unreasonable amounts of time and resources attempting to obtain the payment to which they are entitled * exploitation of the physicians' unequal bargaining power to force them to enter into one-sided contracts * interference with--or obstruction of--the physicians' right to full and timely reimbursement. Bonvino described the charges as a "clear pattern of deceptive behavior" by managed care insurance carriers. "While any of [the charges] individually could be considered a nuisance, it is clear that the range of tactics used by the carriers is deliberate and deceitful. We are asking the courts to bring these tactics to a halt," he said. Bonvino noted that physicians have taken an oath to provide patients with the best possible care. To do this, he said, physicians must be free to make decisions that they believe are in patients' best interests, ones that will not be overruled by insurance companies. "Thousands of physicians are forced to deal as individuals with these multibillion-dollar monoliths that have assumed control over our lives, the lives of our patients, and the practice of medicine," he said. "Our patients can be assured of ... quality medical care only if we address the balance of interests between profit-focused carriers and medically necessary medically necessary Managed care adjective Referring to a covered service or treatment that is absolutely necessary to protect and enhance the health status of a Pt, and could adversely affect the Pt's condition if omitted, in accordance with accepted physician decisions. The continued intrusion of insurance bureaucrats in the patient-physician relationship patient-physician relationship Medtalk A formal relationship that exists between the physician and the Pt, often equated to medical 'duties' that the physician must perform in a professionally acceptable manner. See Doctor-Pt interaction. Cf Abandonment. is destructive and must be stopped." |
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