HEALTH PLAN
NOT LIABLE WHEN IPA INSOLVENT CMA V. AETNA
In California Medical Association v.
Aetna US Healthcare of California (2001) 01 CDOS 10151, the Court of
Appeal held that state law does not require health plans to reimburse
physicians for medical services rendered to plan members after the
physician’s independent practice association becomes insolvent and is
unable to pay.
In CMA v. Aetna, Aetna entered into
agreements with a number of medical groups and independent practice
associations to pay them to process and pay claims from the physicians who
were members of those medical groups and independent practice associations
and who were providing medical care for their patients with health care
coverage through Aetna. The physicians agreed to accept payment from their
medical groups and independent practice associations as payment in full
for the services they furnished to their patients who had coverage through
Aetna. When a number of medical groups and independent practice
associations were in financial trouble and unable to pay their physician
members, the physicians sued Aetna for payment of the services they
rendered to their patients who were covered by Aetna.
The physicians sued under a state law
requiring health plans to timely pay physicians for uncontested claims for
services rendered. The Court of Appeal held that this state law did not
impose an obligation on Aetna to pay the physicians if their own medical
groups and independent practice associations failed to do so.
