Florida doctor sues health plans over out-of-network payments

An orthopedic surgeon says his reimbursements got cut in half, but the plans say they're following the law.

By Tanya Albert, AMNews staff. Feb. 21, 2005.

A Florida orthopedic surgeon says several HMOs are paying him less than half of what they used to for treating emergency patients who subscribe to health plans in which he is not part of the network.

Now he's asking a federal court to step in and make the companies -- Aetna Health Inc., Neighborhood Health Partnership Inc., Health Options Inc. and Vista Healthplans Inc. -- pay what he sees as a fair amount for the services he provides.

Peter F. Merkle, MD, who practices in Pompano Beach, Fla., in January filed a proposed class-action lawsuit in the U.S. District Court for the Southern District of Florida alleging that four health plans conspired to cut their reimbursements to doctors who aren't part of their networks.

"I don't have an ax to grind, I just want to get paid for the work I do," Dr. Merkle said. "If someone submits a bill to me, I pay it. If the plumber comes, I pay the bill. If an electrician comes, I pay the bill. Why is a doctor any different?"

The companies named in the lawsuit deny that they are underpaying physicians and said that they are obeying Florida law.

In Florida, HMOs are required to pay physicians who aren't part of their network by determining which is less: the doctor's charges, the usual and customary charges for similar services in the community where the services were provided, or the charge the doctor and health plan agree to within 60 days of the claim being filed.

Dr. Merkle said the companies he's suing used to abide by that law, but that he noticed that their reimbursement levels changed beginning in the middle of 2003.