Physicians are now seeing the fruits of the Texas Medical Association’s RICO lawsuit labors against the largest nationwide health plans. The awards are coming six years after the battle began. TMA, along with 19 other medical societies, filed a class action lawsuit against a number of nationwide health care payment plans under the Racketeer Influenced and Corrupt Organizations Act (RICO) citing chronic violations of federal antiracketeering laws.

Specifically, the suit alleged that the health plans conspired to defraud physicians and their patients through wrongful medical necessity practices. The plans continued to cheat physicians by failing to reimburse appropriately for medical care provided to patients through artfully designed coding and bundling schemes. Filing complaints for each instance would be an overwhelmingly tedious task for any office or group. Because of your support, organizations like the Texas Medical Association and the Dallas County Medical Society can alleviate this burden allowing you and your staff to concentrate on providing the quality of care that your patients deserve.

To date, more than $11 million has been awarded to Texas physicians from settlements with Aetna, CIGNA, and WellPoint alone. Current aggregate settlements from these lawsuits near $2 billion. Dallas County Medical Society physicians have seen more than $2.4 million awarded for past harm. All of this is money that you would not have seen if it weren’t for the legal success of the Texas Medical Association.

In addition to monetary awards, the suits attempt to reform the operations of the health plans to comply with more reasonable standards and fairer policies when approving treatment and paying for care. As a result, the plans have since made significant improvements from a patient care and physician payment standpoint. The plans have also agreed to contribute millions of dollars to physician-controlled foundations dedicated to supporting your practice and quality of care initiatives.

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Dallas County Medical Society physicians have seen over $2.4 million company settlements:
Aetna
CIGNA
Health Net
Prudential
Anthem/WellPoint
Humana

Soon to Come:
Blue Cross and Blue Shield

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Blue Cross and Blue Shield, along with the Blue Cross and Blue Shield Association, have agreed to a settlement which is waiting for approval. This settlement includes a guaranteed cash payment exceeding $128 million for past harm as well as $878 million in prospective relief from operations changes agreed to by Blue Cross and Blue Shield plans. This is a total of more than $1 billion. Suits against United and Coventry are still in United States Court of Appeals and have yet to be settled.

More information can be found at www.texmed.org/rico or www.hmosettlements.com.
If you would like to stay up to date on Medical Economic and Business of Medicine issues affecting you, please contact Bryan White, DCMS Director of Medical Economics and Quality, and join the mailing list.