Managed Care

California regulators have moved to stop one of the state's biggest hospital operators from billing privately insured patients for unpaid medical services received at its facilities. The Department of Managed Health Care, in a lawsuit filed Friday in Orange County Superior Court, is seeking to bar Prime Healthcare Services Inc.

A federal judge dismissed a lawsuit against two healthcare companies that were sued by a group of more than 600,000 doctors who said the insurers routinely denied or underpaid claims. U.S. District Judge Federico Moreno ruled Monday that there was not sufficient evidence to support claims against UnitedHealth Group Inc. and Coventry Health Care Inc. The companies were two of 10 managed-care companies sued by the doctors in 1999.

In a five-star hotel here, Zhou Jianxiong rises from his seat to toast his new comrades from Southern California. He alludes to Xiangtan as the birthplace of Mao Tse-tung, who sowed the seeds of communism in the Middle Kingdom. "From this place, China's modern revolution spread all over the country," Zhou says, raising his glass of Great Wall red wine. "We also will influence the whole country, like a single spark igniting a prairie fire."

Managed-care company UnitedHealth Group Inc. said Thursday that it would pay $350 million to settle a lawsuit over out-of-network medical claims. The deal comes two days after the insurer pledged $50 million to set up a new database to determine payments for those claims. Another health insurer, Aetna Inc. of Hartford, Conn., agreed Thursday to pay $20 million toward the creation of that database.

HMOs, once the top choice for Americans who get healthcare as a job perk, are so last century. Tightly controlled health maintenance organizations have steadily lost ground over the last decade to preferred provider organizations, which offer greater choice of physicians and hospitals and direct access to specialists -- though at a higher price.

Half a million elderly, blind and disabled Californians now enrolled in Medi-Cal -- including all of those in Los Angeles County -- would be shifted into managed care as part of a complex deal with the federal government, the Schwarzenegger administration announced Wednesday. The pact dictates how California can spend $18.4 billion in Medicaid money over five years and amounts to an overhaul of hospital financing in the state.

State leaders on Tuesday put off until next year highly controversial plans to move 554,000 elderly, blind and disabled Medi-Cal beneficiaries into managed care, costing California $90 million in federal incentives. The decision was part of an overall agreement about how to divvy up $18 billion in new federal funding over the next five years in a way that would ensure no hospital loses money. The Legislature is expected to approve the deal by the end of this week.

California's 10 largest HMOs continue to have "critical shortfalls" and mediocre results in providing preventive care, although overall quality of care has improved and members are increasingly satisfied with their plans, said state officials who released an annual HMO "report card" Tuesday. The annual survey by the state Office of the Patient Advocate rated Kaiser Permanente's Southern California operation the highest, with 10 out of a possible 12 stars.

With their 4-year-old son's life at stake, Mark and Kimberly Zembsch filed suit this week against Health Net, contending that the Woodland Hills-based HMO had refused to let the youngster see the one doctor they believe can treat his rare condition. Jack suffers from metatrophic dysplasia, which causes the spine to twist as its grows, damaging internal organs. The boy lives in Moraga, east of Oakland, but the doctor his parents consider an expert in the disease practices in Delaware.

Only a fraction of the nation's seniors understand the new Medicare prescription drug law, and the more they learn about it, the less they like it, according to a survey released Thursday by the Kaiser Family Foundation. The complex law, which gives private insurance companies billions of dollars to lure beneficiaries away from fee-for-service Medicare and into managed care, will require more than 40 million seniors and disabled persons to make difficult choices about their healthcare.