NewsPage July 24, 1998 Source: AM Best Today's news courtesy of NewsPage - the Web's leading source of daily business news. Florida doctors say prucare's delays cost millions OLDWICK, N.J., BEST NEWS via NewsEdge Corporation : A group representing Florida's 16,000 physicians says the Prudential Health Care Plan Inc. has cheated doctors out of millions of dollars by illegally denying or delaying claims. The Florida Medical Association, the group that represents the doctors, along with the North Florida Obstetrical & Gynecological Association and the Florida Physicians Association, filed a lawsuit against PruCare Tuesday in Duval County Court. PruCare is a subsidiary of the Prudential Insurance Co. of America. The suit says PruCare, based in Roseland, N.J., has rejected several North Florida Ob-Gyn claims, saying patients had other insurance coverage. " Rejection of claims is a matter of Prudential practice" once a patient's claims exceed $1,000 in a year, the lawsuit says. In most cases, "they had absolutely no evidence or reason to believe a patient has other insurance," said Donald Weidner, a Jacksonville, Fla., attorney for North Florida Ob-Gyn and FPA, a physicians' trade group. When claims are denied, doctors must prove patients don't have other insurance, or the patient has to contact Prudential. "The most important thing from the physicians' standpoint is just getting the practice stopped," he said. Prudential officials could not be reached for comment. Weidner said the case could have national implications as doctors begin revolting against how insurers pay them. "A lot of physicians are fed up, " Weidner said. "not just with Prudential, but with a lot of carriers. They all stretch it out and try to use what legitimately is the physician's money." The denials are particularly troublesome for ob-gyn practices, which bill for services after a woman's baby is delivered, Weidner said. Often, PruCare gets the doctor's bill -- always more than $1,000 -- at about the same time it gets the hospital's bill, which is also more than $1,000. PruCare generally denies payment, "then jerks it around for another 30 to 60 days," Weidner said. In some cases, patients pay the bill, believing PruCare won't cover it, Weidner said. For North Florida Ob-Gyn, one third of PruCare's rejected claims were denied because PruCare said the patient had additional coverage from another carrier, Weidner said. The total amount of the claims totaled $500,000, but PruCare has negotiated to pay some of them, he said. Weidner said about $300,000 in claims remains outstanding for North Florida. PruCare has also denied claims, saying it never received them through its electronic filing system, the suit alleges. Weidner said that could be true if the company lost claims occasionally. However, at least a third of North Florida's claims have been lost, he said. Claims are filed through a clearinghouse, then forwarded to PruCare, Weidner said. North Florida has received confirmations from the clearinghouse on receipt of all of its claims, Weidner said. "Either they're losing' claims or they have a problem with their own computer software...and have done nothing about it," he said. [©1998, AM Best] NewsPage is a news service of NewsEdge Corporation ©1998. This content is for your personal use only, subject to Terms and Conditions. No redistribution allowed. ============================================================================== NewsPage July 24, 1998 Source: AM Best Florida Physicians' Lawsuit Surprises PruCare OLDWICK, N.J., BEST NEWS via NewsEdge Corporation : Prudential Health Care Plan Inc., saying it pays almost all of its Florida claims within 30 days, said Wednesday it is surprised by a Florida lawsuit accusing the company of illegally denying and delaying payments. "We do have an excellent track record on claims payments in Florida," Prudential spokesman Kevin Heine said. In Florida, the company pays 92.3% of its claims within 30 days, 97.9% in 45 days and 98.9% in 60 days, he said. The lawsuit, filed Tuesday in Duval County Court by the Florida Physicians Association, the North Florida Obstetrical Gynecological Association and the Florida Medical Association, said PruCare routinely began denying claims once patients' benefits reached $1,000. Prudential denied the claims, asking for information as to whether patients had other insurance. "We were surprised by the complaint because we have been working with this group to resolve their issues," Heine said of North Florida Ob-Gyn. Donald Weidner, attorney for North Florida Ob-Gyn and the FPA, said that through on- going negotiations, PruCare has paid about $200,000 of the practice's outstanding claims, leaving $300,000 yet to be resolved. Heine said delaying claims to coordinate benefits with other insurers is common industry practice. The doctors, however, say PruCare, based in Roseland, N.J., denied claims knowing patients had no other coverage. In some cases, Weidner said, Prudential asked for the information more than once. "When we have the coordination of benefit information, we process those claims routinely," Heine said. "When we don't have the information on the coordination of benefits, we request the information to make sure we're paying the claims properly and not duplicating payments." The class-action lawsuit, which includes all of Florida's 16,000 doctors, also complains that PruCare loses claims filed electronically. PruCare has denied claims, saying they never received them, Weidner said. "The contention that we're somehow systematically losing these is incorrect," Heine said. The company received about 40% of its claims electronically and has a system to confirm each one through a physician's office or an outside vender, he said. PruCare is a subsidiary of the Newark, N.J.-based Prudential Insurance Co. of America, which has an A rating with A.M. Best Co. [©1998, AM Best] NewsPage is a news service of NewsEdge Corporation ©1998. This content is for your personal use only, subject to Terms and Conditions. No redistribution allowed.