MANAGED CARE September 1998. ©1998 Stezzi Communications
The Florida Medical Association and other physician groups in the state have sued Prudential Health Care Plan, charging that the HMO has illegally denied claims or delayed payment. The North Florida Obstetrical & Gynecological Association and the Florida Physicians Association joined in the suit, filed in late July in Duval County Court.
The suit claims that Prudential arbitrarily rejects claims for patients once the cost of their care exceeds $1,000 per year. The suit also alleges that Prudential rejected Ob-Gyn claims on the grounds that patients had other coverage in the absence of any evidence of such coverage. North Florida Ob-Gyn says that Prudential rejected one third of the group's claims last year, worth $500,000, because the insurer said the patients had other coverage.
The lawsuit is part of an ongoing dispute between physicians and managed care plans that is leading physicians to consider the once-unheard-of option of unionizing. In May, delegates at the medical association's annual meeting narrowly voted down a proposal to form a union. Instead, the 17,000-member group decided to create a Managed Care Advocacy Center to collect evidence of HMO "abuses" and share its findings with legislators and the press.
FPA, which is the second-largest physician group in the state with 4,000 members, will present a plan to form a union to a meeting of delegates this fall. To avoid violating federal antitrust rules that bar joint negotiation of rates, FPA plans to focus on noneconomic issues such as clinical autonomy.