Key Judicial Decisions
- In Re Managed Care Litigation - Provider Track Cases (S.D. Fla.)
This class action suit was initiated by a number of physicians and medical societies (state, national, specialty). Managed care companies Cigna, Aetna, Humana, Foundation Health Systems, Prudential and United Healthcare were alleged to have conspired to defraud physicians and other health care providers in violation of the Racketeer Influenced and Corrupt Organizations (RICO) Act; the majority of the defendents settled.
Requirements of the settlements:
Three of the defendants were granted summary judgments. In essence, the court ruled that parallel actions by separate business enterprises, even if those actions may have been illegal, are not, by themselves, sufficient evidence of a RICO conspiracy.
- Defendents must share any edits to CPT codes with health care providers and adopt certain CPT conventions;
- Defendents must spell out the the criteria for "medically necessary" procedures;
- Defendents must reimburse up to several hundred million dollars to the class of plaintiff physicians and create a charitable foundation.
- Klay v. Humana, Inc., 382 F.3d 1241 (11th Cir.(Fla.) 2004)
This is a case of almost all doctors versus almost all major health maintenance organizations (HMOs). The plaintiffs are a putative class of all doctors who submitted at least one claim to any of the defendant HMOs between 1990 and 2002. They allege that the defendants conspired with each other to program their computer systems to systematically underpay physicians for their services.
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