• Texas Doctors Group Joins Class-Action Suits Against Insurers

• Texas District by District: Dr. Tara Rios Ybarra

• This Week In Texas: Mignon McGarry Memos

• Gov. Perry Reappoints Bordelon as Commissioner of Workers' Compensation

• Texas House and Senate Committees ~ 81st Legislature

 
Texas Doctors Group Joins Class-Action Suits Against Insurers
  

By MARIA M. PEROTIN mperotin@star-telegram.com The Texas Medical Association has filed a pair of class-action lawsuits against Aetna and Cigna, accusing the health insurers of using a flawed payment system that cheats doctors and patients. The association, which represents about 44,000 Texas physicians,

joined forces with several other medical groups to file the suits Monday in a New Jersey federal court. They contend that the insurers rely on skewed data from a third party to set their reimbursement rates when patients get care from doctors outside their networks.

"What we hope is that patients will get a better shake," Dr. Bruce Malone, an Austin orthopedic surgeon on the Texas association's board, said Tuesday. "When the networks are inadequate and they have to go out of network, we want it to be fair."

Both insurers issued statements Tuesday saying they would defend themselves vigorously.

At the crux of the lawsuits is the method used by health insurers to calculate the "usual and customary" rates for medical care in an area.

In general, insurers create "networks" of physicians, who sign contracts to accept discounted rates in exchange for the plans steering their members to them.

Patients often are free to seek treatment from out-of-network doctors, but they have to pay a higher share of those physicians' bills. For instance, a patient may pay 20 percent of the tab for an appointment with an in-network doctor, but 40 percent at an out-of-network doctor.

There's another catch: While insurers and their in-network physicians agree on discounted rates ahead of time, outside physicians have no such deals in place. So the insurers calculate what they deem to be the going rate in an area, and pay their percentage based only on that amount. Then, the doctors can charge patients for the balance of the total, nondiscounted bill.

In their suits, the physicians said that Cigna and Aetna set those rates by relying on a faulty database provided by a subsidiary of UnitedHealth Group named Ingenix.

Their methods result in underpayments to doctors and leave patients on the hook for an excessively high portion of out-of-network medical bills, according to the suits.

The New Jersey lawsuit follows an investigation by New York Attorney General Andrew Cuomo, who focused on similar issues and alleged that the Ingenix database intentionally pushed rates downward.

Last month, Cuomo reached a $50 million settlement with UnitedHealth, which agreed to stop using the Ingenix information and to contribute toward a new, independent database. Aetna subsequently agreed to pay $20 million toward the new database as well.

An Aetna spokeswoman said Tuesday that the company hasn't had an opportunity to review the latest suit, but she noted that it's similar to existing litigation.

"We're disappointed the medical community has chosen to litigate on top of already pending consumer litigation on the topic," spokeswoman Cynthia Michener said in a written statement. "If everyone believes they are entitled to additional payments, the healthcare system as a whole will bear the burden. Aetna has developed much improved relations with physicians over the past several years and would prefer to continue collaborative dialogue with them on this topic."

Cigna issued a statement saying the medical associations' lawsuit is without merit, noting that only a small percentage of its claims actually involve out-of-network physicians.

"Cigna's payments to out-of-network doctors are robust and fair, and greater transparency in regards to physician pricing will prove that point," the company said.

As an example, Cigna cites these prices: Health plans pay an average $74 to their in-network doctors and as much as $160 to out-of-network physicians for a 15-minute office visit in New York City. The federal Medicare program pays $70 and $77 to network and non-network doctors respectively for the same visit.

Out-of-network doctors' average charge for that service is $214.

In addition to the Texas doctors, the New Jersey suit is backed by four other state medical societies, the American Medical Association and a handful of individual physicians.

MARIA M. PEROTIN, 817-390-7339
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Texas District by District: Dr. Tara Rios Ybarra
    

Serving for the first term as State Representative for House District 43, Dr. Tara Rios Ybarra proudly represents Cameron, Kenedy, Brooks, Jim Hogg, Kleberg and Willacy Counties in the Texas Legislature. Dr. Tara Rios Ybarra is a born and raised south Texan. She attended high school in her hometown, Corpus Christi, and then went on to continue her education at the University of Texas in Austin. She graduated from Dental School at the University of Texas Health Science

Center in San Antonio with a Doctorate of Dental Surgery. In addition to her educational experience, Dr. Tara Rios Ybarra completed a Forensic Odontology Fellowship at The University of Texas Health Science Center in 2002, which presented her with the opportunity to valiantly serve on the 9-11 World Trade Center Odontology Team which included Mass Disaster training. She has practiced dentistry since 1997 and has owned her own practice for the last nine years. Dr. Tara Rios Ybarra has served as City Council member for the Town of South Padre Island. During her tenure, she has become involved with various projects including the initiation of the Litter-Free South Padre Island and the on going Ecotourism Summit and projects which work towards the formation of a long term beach re-nourishment plan for the state of Texas. Representative Dr. Tara Rios Ybarra convened the 3rd Annual Eco Tourism summit in Kingsville, Texas on October 3, 2008. Dr. Rios Ybarra represents the largest section of coastland in Texas, the Ecotourism summits are part of an on going commitment to improve the economic vitality of South Texas and preserve the environment for future generations. When it comes to community involvement Dr. Tara Rios Ybarra is no stranger. Her community efforts included working on improving indigent health care through the free indigent dental care mobile unit and sitting on the board of the Family Crisis Center which works to end domestic violence. Dr. Tara Rios Ybarra also serves as a Dental Consultant for the U.S. Department of Home Land Security Bureau of Immigration and Customs Enforcement. Lastly and most importantly, she is the mother of two wonderful girls Isabella Skye, 7, and Anastacia, 3. Dr. Tara Rios Ybarra and her family reside in the town of South Padre Island and her thriving dental practice is located in Brownsville, Texas. [top] [back to e-card archive page]

This Week In Texas: Mignon McGarry Memos

Gov. Perry Reappoints Bordelon as Commissioner of Workers' Compensation
 

February 09, 2009 AUSTIN – Gov. Rick has reappointed Rod A. Bordelon Jr. of Austin as commissioner of Workers' Compensation at the Texas Department of Insurance for a term to expire Feb. 1, 2011. The Texas Department of Insurance's Division of Workers' Compensation regulates the workers' compensation system in Texas, ensuring that injured workers receive

necessary benefits so that they may return to work quickly and that workers' compensation costs are kept at a reasonable level for Texas employers. Bordelon is a former public counsel for the Office of Public Insurance Counsel and former advisory member of the Interstate Insurance Product Regulation Commission. He is a board member of the Workers' Compensation Self Insurer Guaranty Association, and a member of the State Bar of Texas and American and Austin Bar associations. He is also a member of St. John Neumann Catholic Church, and a past volunteer with Mobile Loaves and Fishes and Caritas. Bordelon received a bachelor's degree from the University of Texas at Austin and a law degree from South Texas College of Law. This appointment is subject to Senate confirmation. [top] [back to e-card archive page]

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