est intentions, leads to compromises in patient care. Conversely, the HMO’s would argue that stretching limited resources in a regulated manner produces the greatest good for greatest number of patients. One is left with many questions about which priorities are greatest, profit or patient care?In fact, a recent national class action suit filed on behalf of 32 million plan participants by the REPAIR legal team has challenged the five largest HMO’s with just this issue. In addition, REPAIR exposes and attacks several non-disclosed HMO practices of questionable morality: Gag orders, which are arrangements that HMO’s make with participating physicians that to penalize them for advising certain treatment alternatives. HMO determination of “medical necessity” in conflict with physician decision, driven by profit consideration. Limiting patient access to specialists. LawsuitsHMO’s by nature are prone to lawsuits as decisions over coverage frequently disagree with patient / physician decisions. However, this team believes that lawsuits against Humana undermine its devious backbone. Comparison has not led us to believe that Humana is any worse than the other major HMO players are, so perhaps we should group the entire lot of HMO’s as suspect in social responsibility.Forsyth v. Humana. Although still in appeal, Humana was found guilty under ERISA of racketeering charges that in essence allowed the company to receive kickbacks from hospitals in excess of patient costs.Price v. Humana. A RICO (Racketeering Influenced and Corrupt Organizations Act) claim that Humana influenced decisions concerning “medical necessity,” by providing incentives to physicians to deny coverage.Chipps v. Humana. Humana accused of discontinuing coverage for family’s four-year old daughter, Caitlyn, whom was receiving extensive therapy treatment for cerebral palsy. Humana was found...
