Don't know if mom/baby are routinely denied consultation care in some
hospitals (or as out patients) due to medical cost containment by their
HMO's.  In our county I was told there is no coverage once they leave
the hospital.  It becomes an out of pocket expense to see an LC.
Judy Ritchie


http://www.chron.com/cs/CDA/story.hts/health/860279


         March 26, 2001, 11:12PM
         Doctors insist HMOs pay up
         Suits cite conspiracy to cut costs
         Cox News Service

The state medical associations of Texas, California and Georgia
joined individual doctors from seven states on Monday in a federal
lawsuit that accused nine health insurers, including Aetna and Cigna
Corp., of engaging in "a pattern of racketeering activity" to deny
necessary medical care.

The state organizations, which represent more than 75,000 doctors,
contend that the insurers had used "cost-based criteria to approve or
deny claims" for payment and had offered cash incentives to claims
reviewers who would deny or limit tests and treatments that doctors
felt were necessary.

The plaintiffs included individual doctors from Texas, Alabama,
California, Colorado, Florida, Georgia and Kentucky.

The suits are being heard by Judge Federico Moreno of U.S. District
Court in Miami. In addition to Aetna, based in Hartford, Conn., and
Cigna, based in Philadelphia, the defendants are Coventry Health Care
of Bethesda, Md.; Humana of Louisville, Ky.; United Health Group of
Minnesota; the Prudential Health Care unit of Aetna, and three
California companies: Health Net, Pacificare Health Systems and
Wellpoint Health Networks.

Spokesmen for several companies, including Aetna, Cigna and Wellpoint,
said Monday night that they had not seen the complaint and could not
comment.

"As a general matter, many of these suits are similar, and we continue
to believe they are without merit," said David Carter, a spokesman for
Aetna. "We will continue to aggressively defend these actions and are
confident that we will prevail, based on the merits, if the actions
ultimately go forward."

In the lawsuit, the doctors charged that the companies decided which
claims to pay using guidelines based on "purported actuarial criteria,
unrelated to medical necessity."

They contend that the insurers had developed the guidelines with
Milliman & Robertson, an actuarial firm; InterQual, a consulting firm,
and others.

The plaintiffs added that the companies used software sold and licensed
by McKessonHBOC and others that changed standard codes describing
treatments to reduce payments. InterQual, Milliman & Robertson and
McKessonHBOC are not being sued.

The complaint amended an earlier filing that Moreno had rejected for not
clearly showing how the insurers could be accused of violating
anti-racketeering laws.

The new complaint contends that the companies "have undertaken a common
scheme to systematically deny, delay and diminish payments to health
care providers" in violation of provisions of the federal Racketeer
Influenced and Corrupt Organizations Act.

Twenty doctors made specific complaints against insurers they had dealt
with, including violations of state laws calling for prompt payment of
insurance claims. For instance, Michael Burgess, a Texas obstetrician,
said he had been "a victim" of inappropriate determinations of medical
necessity, wrongful denials and delayed payments by Aetna, United Health
and Prudential.

The complaint said the companies had used third-party reviewers,
including Protocare of Santa Monica, Calif., formerly called Value
Health Sciences. The doctors said the reviewers had given "direct bonus
payments and other benefits to claims reviewers who deny a certain
percentage or absolute number of submitted claims" regardless of whether
those claims or hospital admissions were medically necessary.

Kim Ross, a vice president of the Texas Medical Association, which has
37,000 members, said the group's governing House of Delegates had
approved joining the suit after hearing from members.

Dr. Jim Rohack, president of the Texas association, said that "some, not
all, investor-supported health plans" had skirted state laws and
regulations and had prevented "patients from receiving appropriate
medical care."

"The Texas Medical Association is not against all managed care plans,"
said Rohack, who is the medical director of Scott & White, a group
practice and nonprofit health plan in Temple. "But we had to enter the
legal arena to ask a federal judge to stop these abusive practices."

Marie Kushner, a former president of the California Medical Association,
with 30,000 members, said, "This drastic measure by tens of thousands of
physicians is unavoidable because so many other attempts to end these
abuses have been largely futile."

Paul Shanor, executive director of the Georgia Medical Association, with
8,000 members, said doctors in the state "have been frustrated by not
receiving the pay that they are supposed to receive under contracts with
the insurance industry and Georgia law."

Archie Lamb, the lead lawyer for the doctors, said that participation
by "three of the most influential medical associations rebuts the
industry's contention that the complaints of physicians are isolated
or anecdotal or trial-lawyer driven."

"Right now," Lamb said, "the health plans' only accountability is to
Wall Street."

Moreno is also hearing a group of lawsuits filed on behalf of health
plan subscribers. He is expected to rule on May 7 on whether to approve
class-action status for the complaints by both doctors and subscribers.

The managed-care companies are also facing lawsuits seeking class-action
status in state courts in California, Connecticut and New York. Last
week,
a five-judge appellate court in New York upheld the ruling of by a state
Supreme Court judge to hear a suit accusing Prudential Health Care of
breach of contract, deceptive trade practices and fraud.

Cases in California state court are also proceeding against Kaiser
Permanente and Aetna after motions to reject the suits were dismissed.

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