Gee, we're not alone here!

  1. Oh Happy Day!

    Fate Of HMOs To Be Settled In Court
    July 2, 2002

    Watching Dr. Joy Maxey care for her infant patients, one would never pick this Atlanta pediatrician as the type to pick a fight: until you ask her about the average HMO.

    "I'm being cheated," Maxey says. "The fact of the matter is they are not paying the amount of money they agreed to."

    CBS News Correspondent Wyatt Andrews reports so many doctors believe they are being cheated, or at least nicked by managed care, that a half-million physicians today are suing the industry for fraud. Dozens of physician lawsuits have been combined into a single, multi-billion dollar suit in Miami.

    The basic fraud charge is this: When doctors like Maxey perform any service - from checkups to surgery - they note it on a chart next to a five-digit code. This signals the insurance company, in theory, how much to pay.

    The doctors complain that HMOs routinely change the codes, "down-coding" the bill so the HMO pays for services that are less expensive.

    "We believe they have gotten together and methodically have done this in a way to further their bottom line," Maxey says.

    Dr. Tom Deas, of Fort Worth, Texas, has studied how the HMOs reimburse doctors. He says the HMO's all use billing software that by design minimizes payments and too often cheats doctors out of valid charges. Deas is not part of the Miami lawsuit.

    Deas believes the HMOs are deliberately underpaying doctors.

    "They know what they are doing," Deas says. "Each of these little changes and fluctuations in the way they deal with us are games, primarily to avoid payment of appropriate service."

    Stephanie Kanwit, the chief lawyer for the HMO lobby, says, "that's simply not accurate."

    Kanwit says the HMO's do use software to adjust claims but only to protect against abuse. Too often, she says, doctors submit inaccurate or outright padded claims.

    "The software screens claims to ensure they are proper claims, that they are covered claims, that they make sense," Kanwit says. "The doctors need to clean their own house before a few of them bring suits like the lawsuits in Miami."

    There are now two massive federal lawsuits in Miami, this one, on behalf of doctors, and another on behalf of patients that could revolutionize or even destroy managed care.

    The HMO industry says the lawsuits are being driven mostly by rich doctors upset by the loss of once grand incomes. But the doctors believe that a half million physicians with the same complaint can't be wrong and that managed care brought these lawsuits on itself.


    Part One:HMOs Face Racketeering Lawsuits
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    About Sleepyeyes

    Joined: Dec '01; Posts: 3,165; Likes: 59


  3. by   l.rae
    I hope when these HMO ''officials'' die and go to he11 that they get the same quality of choices for their ''plans'' for eternity that they gave their customers for health's this.....
    ...eternity with;
    Plan A; fire:angryfire
    Plan B; fire and brimstone:angryfire
    Plan C; brimstone:angryfire which would you choose for them?.....

  4. by   Sleepyeyes
    heh heh...

  5. by   Repat
    But here's a new twist in the tale - I took my kids for their immunizations to a pediatrician listed as being 'in network' for my insurance plan. The insurance agreement states that if you attend 'in network' practices, you should pay $10.00 co-pay for well child care (including immunizations). I got a bill for $70.00 for 'uncovered services'!! The insurance company says this is not illegal so they can't stop it. Now I wonder what 'uncovered services' I'll be billed for to boost the bill the next time we need to see the doctor(by the way, the $70.00 was for the MA to take vitals). Has this happened to anyone else?
  6. by   TIREDmidnightRN
    I was charged fees for uncovered services...but my insurance had a clause that stated the provider was to accept ONLY insurance payment with NO CHARGES passed on to me..the culprit was the HOSPITAL I WORKED FOR!! I finally, after months of demanding meetings with an elusive patient rep, demanded a copy of all charts..........magic...the bill dissappeared as they were photo copying the chart!!!!!
  7. by   fedupnurse
    Interesting. Downcoding. Kind of like our managers that change our classifications of patients behind our backs to make them look less sick than they really are. Healthcare is full of frauds!!!