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“A lot of good came out of the RICO lawsuit settlement,” Dr. Allen said. “In- surance companies have ceased auto- matically downcoding evaluation and management codes, have generally made their fee schedules available to physicians, have ceased enforcing gag clauses in their physician contracts, and have sped up payment of clean claims.” In addition to business practice changes, the RICO settlements provided funding for creation of The Physicians Foundation and the Physicians Advocacy Institute (PAI). The Physicians Founda- tion works to strengthen the physician- patient relationship, support physicians in sustaining their practices, and help physicians navigate health system re- form. PAI develops projects and tools related to medical practice viability and delivery of quality patient care. Louis J. Goodman, PhD, executive vice president and chief executive officer of TMA, is president and chair of The Physicians Foundation and treasurer of the PAI Board of Directors. Despite agreeing to the terms of the settlement agreements, insurance com- panies don’t always adhere to them. Be- fore the expiration of insurance compa- nies’ settlement agreements in the RICO litigation, physicians could file compli- ance actions if they felt insurers weren’t keeping their promises under the settle- ment terms. Hundreds of physicians and several
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signatory medical societies filed com- pliance disputes to ensure that insur- ers hold to their agreements. Since the inception of the compliance process in 2004, compliance disputes have benefit- ed physicians by more than $29 million. Texas physicians have received about $1.5 million in relief through the com- pliance process. Deborah Winegard, an attorney in the Whatley Kallas Atlanta office, was the CIGNA and Humana compliance dispute facilitator.
“The RICO settlements were definitely worth it because they required the set- tling insurers to change their business practices to become fairer and more transparent to physicians. In addition, through the compliance process, TMA and other signatory medical societies
were able to ensure that the insurers complied with their commitments in the settlement agreements,” Ms. Winegard said.
Although the settlement agreements have expired, many health insurers committed to retain many of the busi- ness changes originally required under their agreements. To review the specific commitments each plan has made, visit
www.hmosettlements.com, and click on the About the Settlements link.
Victoria cardiologists settle CMC lawsuit
In December, three Victoria cardiologists settled their lawsuit against Citizens Medical Center (CMC). The physicians will receive $8 million from CMC and its insurance company and agreed to resign their privileges to practice medicine at the hospital. U.S. District Judge Gregg Costa signed the order to dismiss the three-year lawsuit.
Drs. Ajay Gaalla, Harish Chandna, and Dakshesh “Kumar” Parikh sued CMC, its board of directors, its chief executive officer, and a contracted cardiologist with the hospital. (See “Legal Backup,” October 2011 Texas Medicine, pages 45– 50.) The physicians alleged racketeering, conspiracy, and discrimination in Gaalla et al. v. Citizens Medical Center et al. All of the cardiologists are of Asiatic Indian origin, and all are American citizens. The Texas Medical Association, the American Association of Physicians of Indian Origin (AAPI), and the Ameri- can Medical Association filed an amicus curiae brief in the case in support of the three physicians. The brief argued medi- cal staff privileges are valuable rights, protectable under federal law against ethnic origin discrimination. The physicians said they’re commit-
ted to providing appropriate and high- quality cardiac care to their patients. “The assistance rendered by AMA,
TMA, and AAPI in filing the amicus brief on our behalf in the lawsuit and their
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