HMOs to docs: the check's in the mail

Doctors have griped for years that HMOs have deliberately withheld payment for medical services rendered, while HMOs have indignantly denied doing any such thing.  Two recent news items shed a little more light on this ongoing war of accusations and denials.

A former executive has gone to court to sue Health Net, an Arizona health plan, for deliberately delaying the payment of doctors for legitimate claims, and then firing her when she tried to remedy the unfair practice.  Sally Fernandez asserts that when she took over as VP of operations at Health Net, there were over 300,000 unprocessed claims.  Of these, over 60,000 were over 30 days old, whereas state law mandates disposition on all claims within 30 days.  Fernandez further asserts that when she moved to streamline the process and bring Health Net within compliance of the law, she found that the insurer had instituted a 20-day lag policy, under which no claim was permitted to be examined for at least 20 days after receipt.  When she tried to eliminate this 20-day lag policy, she states, she was denied permission to do so because timely processing of the claims would constitute a financial burden to Health Net.  When she complained some more, they canned her.

In a related story, New Hampshire physicians are complaining that Anthem Blue Cross Blue Shield, in skirting a new state prompt-payment law, may be even further delaying payment on claims.  The doctors, who are considering taking Anthem to court, assert that Anthem is taking advantage of a loophole in the law that permits insurers to issue a "claim pending" letter instead of actual payment. The "claim pending" clause is intended to allow insurers to get additional information on claims.  But doctors complain that the letters are simply being used as a stalling tactic, while insurers ever so slowly investigate such simple issues as member eligibility.  Doctors also say that Cigna, another large insurer in New Hampshire, simply delays payment without bothering with the nicety of the "claim pending" letter (thus avoiding, we hasten to add, wasting member's valuable health care premiums on postage stamps.)

Both Health Net and Anthem have issued statements to the effect that they are scandalized by the allegation that they are unreasonably delaying payment on claims.  And they will see everyone in court.

DrRich comments:

There's really not much to add except: Did anyone really expect that the mere passage of laws would induce insurers to do what they should have been doing all along?  They have made a simple business decision.  Apparently, the money they save by delaying or denying legitimate claims is far more than whatever fines and penalties they are likely to incur after a long court battle.  Heck, with luck they'll be able to string these lawsuits out long enough that they'll be out of business before anything is settled anyway.

Remember - the Clintonians are hard at work to bring down private health insurance.  A chief mechanism by which they will do that is by expanding the right to sue HMOs and managed care companies (not, as we can plainly see, that suits against these entities are rare today.)  Clintonians are fighting to the death (they want us to believe) for our right to sue unresponsive and irresponsible HMOs.

Except, of course, that the Clintonians' end game is the "rescue" of the dying health care system by the government.  And once the government is running health care - well, then try to sue your insurer.  Just ask the doctors who, while complaining so vociferously about the delayed payments by HMOs, are not permitted to sue Medicare when (as is their practice) they do exactly the same thing. 

September, 2001

Back to news and commentary

YourDoctorintheFamily.com Home Page