Patients in middle of battle between doctors and HMOs

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Posted 6:50AM on Monday, November 11, 2002

ATLANTA - A case before a federal appeals court could help decide whether doctors or insurance companies make medical treatment decisions for their patients. The 11th U.S. Circuit Court of Appeals is expected to soon decide whether to hear an appeal seeking to throw out a lawsuit against the nation's largest health maintenance organizations. If the court doesn't take the case, it will go to trial. The case is important because it could determine who gets to decide what treatments are in a patient's best interest - the doctor or the managed care company. But if the case is allowed to proceed, legal experts say HMOs may settle the case rather than pursue an expensive court battle, either of which could cause escalating health care costs to go up even more. The lawsuit pits more than 600,000 doctors nationwide against the HMOs, with millions of patents caught in the middle. The doctors claim the HMOs have engaged in a racketeering conspiracy by illegally delaying and denying reimbursement of health care costs. The doctors also accuse the companies of fraudulently rejecting expensive but necessary medical treatments. "One of our goals is to allow medical necessity decisions to be made by doctors, rather than computers and claims adjusters," Atlanta lawyer Ken Canfield told the Atlanta Journal-Constitution. Canfield represents the Medical Association of Georgia and four Georgia doctors who are among the lead plaintiffs. The health care companies argue that it is the doctors who are at fault for rising prices for office visits and medical treatments. The HMOs say there are mechanisms in place that allow doctors to resolve their payment disputes. The case could force HMOs to abandon "cost-containment principles that have kept health insurance affordable for many Americans over the past two decades," according to the organizations' appeal. An averse ruling "threatens to precipitate a major upheaval in the nation's health care system." The suit seeks unspecified monetary damages and ways to make health care more responsive to the needs of patients. Defendants in the case include Aetna, Anthem, CIGNA, Coventry Health Care, Health Net, Humana, PacifiCare Health Systems, Prudential Insurance, United Health Group and WellPoint Health Networks Inc. The HMOs are asking the 11th Circuit to reverse a September ruling by U.S. District Judge Federico Moreno of Miami, who certified the class action case on behalf of the doctors. The doctors "have done more than just allege a common scheme; they have demonstrated facts which support its existence," the judge said.