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Managed Care Litigation Lawyer in Houston, Texas

managed care litigation

Managed care litigation, also known as In Re Managed Care, can begin with a single claim in one state or multiple claims across the country. Health care providers and policyholders who are affected by the practices and business structures spread across plans in multiple regions under the management of an HMO have the right to pursue claims against the HMO or MCO (managed care organization), alleging violations including:

  • Antitrust violations
  • RICO Act violations
  • Payment practices claims
  • Unfair business practices claims

At Reich & Binstock, we have extensive experience pursuing multidistrict litigation (MDL) claims on behalf of health care providers in Texas and throughout the United States, dating back to the late 1990s when these HMO/MCO business practices began. Call our law office today at 713-622-7271 to schedule your free and confidential consultation.

Attorney Dennis Reich is appointed Chairman of the Damages Committee in the Blue Cross Blue Shield antitrust litigation.

Managed Care Abuse Litigation

This is an incredibly complex area of law that requires great skill and experience to litigate. As we’ve stated many times in the past, insurance companies very rarely have their policyholders in mind when they make decisions. They are for-profit companies that will do anything to cut costs and save money. Thus, they have a tendency to delay or even completely deny care for patients, even if medically necessary. 

At Reich & Binstock, we refuse to stand idly by while our clients suffer at the hands of corrupt, greedy health insurance companies. That’s why we have successfully tried many cases involving the managed care industry. When your medical needs aren’t being met by your insurance company, you need a qualified attorney who understands the procedures and processes of these companies. With our knowledge and experience, we will put you in the best possible position for a favorable outcome in your case. Contact our Houston insurance claim lawyers for more information.

What Is Managed Care?

managed care abuse litigation

Managed care plans are very common for those who have health plans. A managed care company essentially has two goals: lowering costs and maintaining the quality of medical treatment. Many managed care health plans are already popular for consumers when choosing their healthcare plan. In fact, most popular insurance coverage plans offer certain services that a managed care plan will offer. These features include the following.

  • In-network providers and out of network providers
  • Oversight of providers
  • Tiers of prescription medications

There are many other aspects of managed care plans that other healthcare plans also include. The main intention behind a managed care plan is to carefully manage health care costs for payments while also maintaining a high standard of care.

How Can Managed Care Benefit You?

It’s important to remember that many people choose managed care plans because of their services, coverage, deductible, and cost benefits. These medical care plans have many benefits for many people. However, when the companies act in bad faith, they can leave a bad impression of insurance companies in general. Below, we list some of the benefits of managed care plans.

  • Lower medical care costs for members without sacrificing the quality of the healthcare, especially when using in-network doctors
  • Referrals and care are accomplished quickly through in-network hospitals and doctors.
  • Information and medical records travel quickly within the network. This is the case even if you see two different in-network doctors in completely different cities.
  • Patients get to choose their physician, so they can establish good relationships with those providers.
  • With the implementation of accreditation mandates, patients have the reassurance that their physician will meet certain minimum guarantees for care.
  • Prescription management becomes much easier because these organizations often work closely with pharmaceutical companies.

Types of Managed Care Plans

indemnity vs managed care

Preferred Provider Organizations (PPO) allow you to see any doctor or provider you want, regardless of whether or not they are in your network. However, you will often pay less for in-network services. There also might not be any primary care physician requirements for referrals. As with HMOs, preventive care is 100% covered. Basically, you have more flexibility for higher costs.

Health Maintenance Organizations (HMO) require you to receive medical services only from in-network physicians and providers. The tradeoff is having a lower monthly premium. These organizations also require you to have a primary care physician before you seek help from another doctor. Additionally, you do not receive reimbursement for visits to out-of-network providers. Basically, you have less flexibility for lower costs. Another benefit is that you receive 100% coverage for preventive care.

Point of Service (POS) plans are a sort of hybrid between HMOs and PPOs. You can see physicians both in and out of network, but you will pay higher costs. They might also require that you see a primary care physician before you can seek a referral or change doctors. In essence, you get more options with lower costs.

Exclusive provider organizations are also hybrids between HMOs and PPOs. Just like HMO members, you may not be required to see a PCP for referrals. However, you will often need to see in-network providers for reimbursement or coverage. This type of managed care plan usually costs more than an HMO, but less than a PPO.

Indemnity vs Managed Care

managed care vs indemnity

Indemnity insurance plans are notably different from the plans we discussed above. They are also called “fee-for-service” plans. Basically, you can choose your providers and your hospitals. The indemnity insurance company then pays for a specific portion of the services. However, you will likely need to pay upfront costs, then file for reimbursement from that insurance company. 

Additionally, these plans often have annual deductibles to meet before the insurance company pays your claims. Once you meet the deductible, they will pay the UCR (usual, customary, and reasonable rate) for the services you had. The UCR is the average rate that a physician in your area will charge for a particular service.

Why Is Managed Care Controversial?

Earlier, we discussed some of the notable benefits of having a managed care insurance company. Now we’ll cover the notable downsides of choosing these plans for your medical care.

  • Limited care for those without insurance, meaning patients could be forced to go to the emergency room
  • Very strict rules lead to patients seeking help from expensive out-of-network providers if they are not satisfied with the care they receive
  • Because of the necessity of referrals for advanced care, patients must take matters into their own hands to receive this care.
  • Needless services are requested in order to increase the billing submitted to insurance for reimbursement.
  • Wait times can be very long because of the lack of doctors entering the networks.

MDL Managed Care Litigation Against HMOs/MCOs

Antitrust lawsuits seek financial injury compensation and corrective measures for damages caused by HMO licensing pacts that create geographic boundaries and allocate health insurance markets among the plans. Such practices stifle competition and consumer choice. An environment is created in which premiums can be increased significantly, and health care providers can experience substantial financial injury. In the case of Blue Cross Blue Shield litigation, antitrust violations are spread across its 38 regional member health insurance plans across the nation.

Payment practices lawsuits involve HMO claim payment failures and refusals, according to provider contracts. Additional claims we handle on behalf of health care providers involve HMOs downcoding and bundling charges, which reduces the amount due in claims substantially.

RICO Act violations in managed care litigation also involve wrongfully and fraudulently paying health care providers less than they are owed for services and procedures.

Unfair business practices lawsuits involve HMO tactics and strategies to limit the number of physicians approved to treat policyholders in the insurance plan. The HMO may then limit patient volumes and business relationships between medical practices. In such cases, our law firm can hold the HMO liable for causing health care providers to lose income as a result of negotiated lower fee schedules.

Speak With a Managed Care Litigation Attorney in Houston

We offer comprehensive representation and advocacy to handle all communications with the HMO/MCO and all legal aspects in your best interests. Please call our firm in Houston at 713-622-7271 or contact us confidentially through our online form to schedule a meeting with one of our lawyers. We are one of the few law firms with significant and long-term experience in this field, so you can rest assured that your case will be handled quickly and efficiently.

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There is never a fee unless we recover on your behalf.
Additionally, clients are not obligated to pay expenses if a recovery is not made.

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