Conn. Physicians Sue Insurers, Alleging They Favor Designated Doctors

By | August 16, 2007

A Connecticut physicians group has sued three insurance companies, claiming they steer patients to certain doctors designated as elite to cut costs.

In a lawsuit filed in Danbury Superior Court, the Fairfield County Medical Association accused Cigna Corp. and UnitedHealth Group of designating endocrinologists, dermatologists, obstetricians and other specialists as elite and charging patients who see them lower copayments.

The lawsuit — a new battle between doctors and insurers over how to stem rapidly rising health care costs — accuses Cigna, based in Philadelphia, and UnitedHealth in Minnetonka, Minn., of damaging the reputations of physicians who are not designated by the insurers.

UnitedHealth has yet to start the program, the Fairfield County Medical Association said Tuesday. But the lawsuit seeks to stop UnitedHealth before it establishes the program, said Burton Rubin, a Greenwich physician and president of the doctors’ group.

The lawsuit also accuses Cigna and UnitedHealth of seeking greater profits by steering patients to specialists who provide care at a lower cost without regard to quality.

“As such, the programs are a fraud upon the public and a libel against the plaintiff physicians,” the 1,800-member medical association said in its lawsuit.

The lawsuit, filed last month as a class action claim, also names Oxford Health Insurance, which was bought by UnitedHealth. Oxford has not established a physician designation, but participates in the UnitedHealth program, the lawsuit said.

The lawsuit also seeks monetary damages yet to be determined.

Wendell Potter, a spokesman for Cigna, would not comment on the lawsuit. However, he said in an e-mail that Cigna uses standardized performance measures and “what we believe to be the best data available.”

“We recognize that the quality and cost efficiency measures we use represent only a partial assessment of a provider’s quality and cost efficiency and we advise members that these evaluations should not be the sole basis for decision-making,” Potter said.

Tyler Mason, a spokesman for United HealthCare, said the lawsuit is “without merit.”

“Employers and consumers of health care services want and need reliable data to help make important health care decisions, especially as they are becoming responsible for paying a greater share of their health care costs,” he said. “This is a national consumer trend.”

Claudia Gruss, a gastroenterologist and chairwoman of the board of trustees of the county medical association, said so-called tiered networks have been in use for a while, but some insurers are “more forthcoming” about their standards than others.

Insurers base physician designations on insurance claims data, not evaluations of patient care, Gruss said.

“What we’re saying is that the tiered network is being touted as promoting doctors who somehow provide superior care. It’s a matter of economic credentialing and not improving care,” she said.

Jeffrey Carton and Barry Cepelewicz, White Plains, N.Y., lawyers who represent the Fairfield County Medical Association, say the practice is becoming a trend.

Aetna, for example, offers Aexcel, which encourages members to choose specialists who have “demonstrated effectiveness in clinical performance and cost efficiency.”

Cole said officials at Aetna, unlike Cigna and UnitedHealth, have talked to doctors about ways to improve its program.

Carton said the lawsuit should force the insurers to divulge in detail why they designate some doctors and not others.

“Doctors don’t know how they were designated by insurance companies,” Carton said. “They’re just as confused as those not getting the designation.”

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