TeamGail.com

Recently the AMA filed class action lawsuits against Aetna, Cigna and Welpoint for underpaying out of network claims. The AMA was also recently awarded $350m against United Healthcare for the same allegations.

In recent years some of these same industry giants lost litigation related to denying claims for medical necessity. In those class-action lawsuits, physicians alleged that many of the nation's largest insurance companies delayed or denied reimbursements for health services and illegally rejected claims for necessary medical treatments as part of a racketeering conspiracy. Doctors claimed that their medical services were "downcoded" by insurance companies so that reimbursements would be smaller.

In 2005 Wellpoint became the fifth company to settle claims brought by more than 700,000 physicians against major U.S. health insurers. Aetna settled in May 2003, followed later that year by Cigna. Health Net and Prudential Insurance, which sold its health insurance business to Aetna, also settled in 2005.

Including the WellPoint settlement, the insurers' settlements up to 2005, totaled $590 million in cash.This consisted of $367 million for physicians, $40 million for a not-for-profit health care foundation and $183 million in attorneys' fees.

Industry analysts at the time and still today predict that WellPoint and the other insurance giants will likely increase premiums to cover the lawsuit's cost -- which includes lawyers fees, payments to doctors and implementation of new billing systems - WHO PAYS FOR THIS?! SALLY & JOE, me and you - that's who!

In May of 2007, 23 Blue Cross and Blue Shield Association plans settled a class action lawsuit filed by 900,000 physicians. Under the settlement, the BCBS plans will contribute $128 million to a fund to which physicians can submit previously disputed claims and pay as much as $49 million in legal fees. In addition, BCBS plans agreed to establish new external review boards to address disputed claims, make their fee schedules and reimbursement explanations more transparent, standardize definitions and review procedures used to determine whether services are medically necessary.

In an article written July 13, 2005, Medical News Today quoted WellPoint CEO Larry Glasscock in a statement that said, "We see this agreement as a very important step in further collaborating with physicians" (Miami Herald, 7/12/05). Sam Nussbaum, WellPoint's executive vice president and chief medical officer, said, "This agreement ... will also help to support more efficient and high quality health care that will enable physicians to spend more time with patients and that ultimately benefits everyone, including our members" (AP/Hartford Courant, 7/12/05).

This article also quoted Michael Sexton, president of the California Medical Association, who said WellPoint "will no longer be in the exam room with the physician and patient," adding, "The patient will get the appropriate care they need when they need it" (Washington Post, 7/12/05).

Yeah...right.

HAS ANY OF THIS RESULTED IN SAVINGS TO CONSUMERS?!

Lower medical bills?

Reduced premiums?

Less red tape?

More time with your doctor?

Less denied care?

IS THERE ANY LESS ADMINISTRATIVE EXPENSE FOR PROVIDERS?

REDUCED ADMINISTRATIVE EXPENSE FOR INSURANCE COMPANIES?

I welcome replies from just ONE consumer who can say he has saved time or money from any of this litigation, or who thinks he is protected from balance billing, and not caught between his provider and his insurance company, save for a few isolated HMO participants.