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.

AMNews: Oct. 8, 2007. Court rules Medicare plans can be sued for nonpayment ... American Medical News


  1. Does this mean that Anthem will have to pay for my gastric bypass if Medicare does not approve it since Virginia requires its insurers to cover gastric bypass. Medicare is discriminating against me by requiring me to wait 6 months plus and prove all these things to them that my doctors already know and agree on. For example they want a monthly chart of progress including vital signs etcetera for weight loss efforts even though the reason they are supposed to pay for gastric bypass is because people really cannot lose the weight on their own.


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