Doctor-HMO Fee Battle Headed for US High Court

November 22, 2002 ( - A bitter battle between giant US health maintenance organizations (HMOs) and 600,000 doctors over how much the physicians get reimbursed for HMO patient care is headed for the US Supreme Court.

Reuters reported that lawyers for HMOs won a green light from the US 11 th Circuit Court of Appeals in Atlanta to ask the Washington high court to rule on the doctor fees issue.

The immediate appeal grows out of a September ruling by US District Judge Federico Moreno of the US District Court for the Southern District of Florida allowing claims by 600,000 doctors against the HMOs to be tried together as a group.

The original doctor lawsuits filed two years ago in Miami accuse the HMOs of defrauding doctors by not reimbursing the full amount requested in medical claims.

While Moreno agreed to certify the doctors’ claims as a class action, Reuters said he declined to grant class action status to an estimated 145 million HMO patients who also sued the HMOs, alleging they were denied optimum medical care.

Brian Boyle, an attorney for the HMO defense team, told Reuters that the defendants would ask Moreno to put evidence gathering going on at the trial level on hold until the Supreme Court appeal moves forward.

“This is a highly significant ruling and clears the way for the defendants to correct what we think is a manifestly erroneous class certification order before having to participate in a mammoth, costly and clearly unfair trial,” Boyle said in a written statement, according to Reuters.

Evidence Gathering Could Cost Millions

Reuters said the HMOs want the evidence gathering delayed until after the appeal since pulling together the information needed could cost them millions of dollars because the plaintiffs have asked the companies for virtually every piece of paper they have generated in the last ten years.

Plaintiffs lawyer Archie Lamb said the appeals ruling was no surprise and should not interfere with the collection of documents, the examination of software programs used by the HMOs to pay doctors’ bills, and the pretrial questioning of HMO executives now under way.

“Judge Moreno’s ruling was well reasoned and well founded in law,” Lamb told Reuters. “We’re in this for the long haul, and I’ll be surprised if they (judges on the appeals court) don’t uphold his ruling.”

Lamb said the appeals process would involve written and oral arguments and would be open ended, since the appeals judges have no deadline for ruling on the class-action status of the case. Moreno has set trial for May 19.

Plaintiffs in the case include medical associations in California, Texas, Georgia, Florida, Louisiana and other doctors’ groups.

Defendants in the case include Aetna, CIGNA, Humana, Foundation Health Systems, now known as Health Net Inc, UnitedHealth Group Inc., PacifiCare Health Systems Inc and WellPoint Health Networks Inc.