Four hundred Tarrant County doctors filed a class action lawsuit against Harris HMO, alleging that the physician payment system in its plan violated Texas insurance laws. In the lawsuit, which was filed in the 352nd District Court, the physicians asked Judge Bonnie Sudderth to issue a temporary injunction preventing the HMO from enforcing monetary penalties against doctors who overspent their budget in issuing prescriptions to patients.
The law in Texas at the time the case was filed provided that managed care entities could not establish physician payment systems which created financial incentives to limit medically necessary care to patients.
At the temporary injunction hearing, the undisputed evidence established that physicians who spent less than budgeted amounts received bonuses from the HMO, while doctors who exceeded their budgets were penalized. At that point in time, the HMO had imposed millions of dollars in fines against the physicians who had exceeded established budgets. The doctors argued that they shouldn’t be forced to choose between their bottom lines and their patients’ best interests.
In issuing the requested injunction, Judge Sudderth found that the HMO’s practices resulted in the denial of medically necessary care to patients. “These denials include circumstances of cherry-picking, patient-dumping … and outright denials of treatment, referrals and prescriptions,” Judge Sudderth explained, in ruling in favor of the requested injunction.
A few months later, the Texas Insurance Department levied an $800,000 fine against the HMO for violations of state insurance regulations that prohibit health plans from using financial incentives to encourage doctors to withhold medically necessary care. Shortly thereafter, the HMO announced its plan to do away with the caps on prescription spending in physician contracts and to compensate the doctors who had been fined for exceeding their budgets. Within a few days of this announcement, the parties entered into settlement negotiations which resulted in the eventual settlement of the lawsuit.