The Florida Medical Association Joins a Federal Lawsuit Against Health Plans.

Business Editors/Health, Medical & Legal Writers

TALLAHASSEE, Fla.--(BUSINESS WIRE)--Aug. 29, 2001

On Wednesday, August 29, 2001, the Florida Medical Association President Terence P. McCoy, M.D., announced that the FMA is joining the California, Georgia and Texas Medical Associations in a federal lawsuit against health plans.

The for-profit HMOs named as defendants include Humana, Inc., Aetna Inc., Cigna, United Health Care, and Prudential Insurance Company of America. The suit charges the plans with enriching themselves at patients' and physicians' expense, violating federal Racketeer Influenced and Corrupt Organizations Act (RICO) laws to defraud physicians, unilaterally breaking contracts with physicians, and otherwise eliminating the patient and physician from the important health care decision process. Specifically the complaint alleges that the health plans:

-- Systematically cheat doctors by manipulating claims handling software to
guarantee denial of payment for care already rendered

-- Violated Florida and other state prompt pay laws

-- Define medical necessity based on cost rather than what the patient and
physician believe to be necessary

-- Deliberately delay payments in order to benefit the health plan financially
and in consequence stress the delivery system

-- Provide financial and other incentives to claims reviewers who deny claims

"The Florida Medical Association has tried for years to convince the Florida legislature that HMOs, just like everyone else, need to be held accountable for their actions. We recently passed Prompt Pay legislation, but this legislation does not work as long as the HMOs continue to find loopholes in the law. Our duty, as physicians, lies in doing what's best for our patients, not in what's best for the insurance company," stated Dr. McCoy.

Physicians have been held victim to downcoding, bundling, delayed payments, wrongful denials, inappropriate medical necessity determinations, and increased administrative expenses. These health plans have systematically denied, delayed and diminished payments to health care providers. They have taken physicians' payments and diverted them for their own profits. Without adequate and timely payments, physicians cannot maintain their practices and cannot provide the continuity and quality of care that patients require.

"The Florida Medical Association will continue to seek every measure possible to hold HMOs accountable," stated H. Frank Farmer, M.D., FMA President Elect. "With the 2002 Legislative Session just around the corner, a top priority for the FMA is Prompt Pay Legislation. We will also continue to work with the AMA to pass a meaningful Patients' Bill of Rights," continued Dr. Farmer.

Archie Lamb, co-lead counsel in the Miami lawsuit, heralds the decision by the FMA as a real turning point in the fight for managed care reform. "Our lawsuit is simple. It demands that HMOs stop cheating. With the FMA's involvement the number of Medical Association members involved in Miami reaches almost 100,000. Dr. McCoy, Dr. Farmer, and the FMA join the California Medical Association, the Texas Medical Association, and the Medical Association of Georgia in saying to HMOs enough is enough. Quit playing doctor with our patients. We simply must put the doctors and patients back into the health care decision equation."

The Florida Medical Association serves as an advocate for physicians and their patients to promote the public health, to ensure high standards in medical education and ethics, and to enhance the quality and availability of health care.

The Florida Medical Association, along with its component medical societies, is the largest, most effective organization representing interests of all Florida physicians and their patients. The FMA provides its 16,000 members with a strong voice and active representations in the state legislation, medical ethical and legal affairs, medical economics, and practice issues.