Insurance watchdogs push compliance with settlements: AMNews interviews Robert W. Seligson

As tensions between physicians and managed care persist, the president of Physicians Advocacy Institute talks about holding insurers responsible for doing good business.

By Amy Lynn Sorrel, AMNews staff. Aug. 20, 2007.

Out of physicians' nearly decade-long legal fight against health plans' unfair reimbursement tactics arose the Physicians Advocacy Institute Inc.

The organization, whose board is made up of executives from nine state medical societies and a lead physician plaintiff, has been up and running since early 2006. Its mission: to fight for physicians to make sure health plans stick to the settlement terms.

The oversight entity was established with funds from the 2005 settlement with Prudential Insurance Co. of America -- one of eight similar class-action settlements reached with the country's major insurers, who agreed to alter the way they pay doctors. In all, the settlements amount to $2.5 billion, including cash, future payments and business changes.

Robert W. Seligson, the PAI's president, talked with AMNews about the organization's work to help doctors resolve claims and what lies ahead to keep up with managed care's evolving business practices.

AMNews: Briefly describe the PAI and its purpose.

Seligson: We took on managed care in court because there was no other recourse for physicians who were sick of all the administrative and payment games that insurers were playing. We haven't fixed every problem, but we sure got the health insurers to pay attention and to know that PAI means business, even when the settlements expire. Our purpose is to continue the momentum gained by the lawsuits and hold health plans accountable to the terms of the settlements and to give physicians the tools necessary for them to maintain viable practices. ... We have a team of general counsels from state medical associations across the country watching for any signs of noncompliance by insurers. ... Compliance dispute facilitators are appointed by [the doctors' attorneys] and are physicians' advocates for each settlement.