Tennessee Doctors Fight MCOs’ ‘Unfair Tactics’ to Reduce Payment, Limit Patient Services

Doctors in Nashville have "tak[en] up arms" against what they call "unfair tactics" that health insurance companies use to reduce their pay and limit services to patients, the Nashville Tennessean reports. Since last October, 100 local doctors have joined an AFL-CIO-affiliated union to help them negotiate insurance contracts, and Urology Associates has filed suit against Cigna Healthcare of Tennessee, alleging "breach of contract and failure to pay claims." The Tennessee Medical Association also has sought "relief" from the state Legislature, which has considered a number of bills that would strengthen doctors' "bargaining position" and allow patients to sue health plans for denials of necessary care. However, insurance company officials maintain that they have to balance physicians' concerns about adequate reimbursement with the "need to keep health insurance affordable" for employers and enrollees, "citing a double-digit increase in health costs -- which has "forc[ed]" premiums "in the same direction." Ron Harr, a spokesperson for BlueCross BlueShield of Tennessee, said, "We don't try to keep people from getting the health care they need, but at the same time, our customers (primarily employers) are coming to us and saying, 'We can't afford to pay you anymore.' We're in this terrible box."

'Skeptical' Doctors, Health Plans
Still, doctors remain "skeptical." Dr. Philip Bressman, a Nashville OB/GYN, said, "The vast majority of insurance plans have very large surpluses. The CEOs made their bonuses last year. I have a hard time with the concept they're struggling," adding that reimbursement rates have "continued to go down and down." To help in negotiations with insurance companies, Bressman led efforts to join forces with the Federation of Physicians & Dentists, a Florida-based union affiliated with the AFL-CIO. About 70 OB/GYNs and almost 30 ear, nose and throat specialists have joined, he said. Although the union cannot demand rate increases for health professionals "as a group" under federal law that prevents most doctors from bargaining collectively, the organization has begun to analyze and negotiate contracts with insurance companies on behalf of individual doctors or physician groups. Bressman said, "I'm not asking to double my reimbursement. I'd just like to see a recognition that as costs go up, we may need a little bit more of a cost-of-living increase, like everybody else gets." However, Susan Pisano, a spokesperson for the American Association of Health Plans, said that while reimbursements for some physicians have "remained static or declined," the "average physician income continues to rise." Physicians also can "gain leverage" in negotiations with insurance companies by joining "large group" practices, she said, adding, "One of the things being cited as upward pressure on health care costs is consolidation within the provider community." In addition to low reimbursement rates, doctors maintain that insurance companies refuse to reveal fee schedules -- lists of payments for services -- during negotiations with physicians, have "whittled away" covered services and modified reimbursement rates after signing contracts with physicians (Snyder, Nashville Tennessean, 5/5).