LAT:WellPoint to Heed Drs' Wishes When Paying for Treatment(landmark case)

[DeepModem Mom]

WellPoint to Heed Doctors' Wishes When Paying for Treatment
By Lisa Girion, Times Staff Writer


In a legal settlement that doctors said would remove an insurance company from the examining room, WellPoint Inc., the nation's largest health insurer, agreed Monday to cover virtually any established treatment -- without regard to cost -- that a physician deems necessary.

If approved by a federal judge, the deal calls for WellPoint to spend at least $390 million to settle two class-action lawsuits by more than 700,000 physicians who charged the company with systematically underpaying them and putting its financial interests ahead of patient care....

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As part of the settlement, WellPoint will adopt a patient-friendly definition of "medical necessity" that mirrors the American and California medical associations, and it would put the burden on the company of proving that a cheaper treatment is acceptable.

WellPoint will also make notable changes in the way it reimburses physicians and considers their treatment recommendations at a minimum cost of $250 million, the company estimates. It includes a ban on WellPoint's alleged use of computer programs to systemically deny and underpay purportedly legitimate patient claims....

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The landmark litigation began as a series of lawsuits filed by the California Medical Association and its sister groups in 1999 and 2000 against 10 of the biggest managed-care companies. The doctors alleged the HMOs' heavy-handed business practices amounted to extortion and fraud-violations of the federal Racketeer Influenced Corrupt Organizations Act....


http://www.latimes.com/business/la-fi-wellpoint12jul12,0,2339821.story?coll=la-home-headlines

[Betsy Ross]

1. A court decision that doesn't make me sick. n/t

[iverglas]

2. wow - just as it's always been in Canada ;)

The provincial health plans are required, by the federal legislation and funding arrangements, to cover all "medically necessary" treatments.

The term isn't defined in the legislation, and the provinces establish detailed fee schedules setting out what services are covered and what services aren't. If they try messing around with the definition, they're liable to a loss of funding, and that doesn't make the voters happy.

For example, a vasectomy or tubal ligation is covered; an attempted reversal is not. Prenatal care and delivery, and postnatal care, and so on, are covered in all cases; so is abortion.

No doctor ever has to consult an administrator or bureaucrat before providing treatment, ordering tests or xrays or scans, or prescribing medication. (Medication is covered by public plans in only a few provinces, but is covered for seniors and the low-income in the others.)

And doctors never have to argue about the price of their services, or chase insurers (or patients) to collect.

And the damn thing is ... it's way cheaper - for the public and for physicians themselves - to do things that way.

http://content.nejm.org/cgi/content/short/349/8/768

The unfortunate perverse effect of this decision might be that physicians have less incentive to support calls for universal public-payer health insurance.

[DeepModem Mom]

3. Thanks for this info, iverglas. nt