As this article states from the court decision, payers can be sued for non payment, even if the funds were administered by an HMO/IPA...Pacificare case is still being settled as well when an IPA went bankrupt and couldn't pay the claims...Pacificare was still held accountable when sued by several physician's groups. BD
A recent Texas Supreme Court decision gives physicians and hospitals a remedy when health plans don't make payments under Medicare Advantage contracts, doctors and lawyers say. The state high court on Aug. 31 ruled that a group of Texas hospitals can sue Aetna in state court for allegedly failing to reimburse them. This means the facilities won't have to go through the Medicare administrative appeals process.
A trial judge recently ruled that even when an HMO delegates reimbursement or other duties to another entity, the insurer "may not avoid its ultimate liability for the delegated entity's failure to comply with the applicable statutes and regulations" and remains subject to the Texas prompt-payment law. Doctors could recover up to $8 million, the TMA stated.
Officials from UnitedHealthcare, PacifiCare's parent company, did not return calls for comment.