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Reviews of Gold Plus Plan sought

Two Florida congressmen are calling for federal investigations into the operations of the Humana Gold Plus Plan, the nation's largest Medicare health maintenance organization. Republican Rep. E. Clay Shaw of Fort Lauderdale and Democratic Rep. Larry Smith of Hollywood asked for the investigations after the Fort Lauderdale Sun-Sentinel ran a series of articles about the health-care plan, which has about 200,000 clients _ 177,000 in Florida.

Shaw asked the House Ways and Means Committee's oversight subcommittee to hold hearings, and Smith asked the U.S. General Accounting Office, the auditing arm of Congress, to review the HMO's operations.

The federal government expects to pay Humana almost $650-million this year to run the Gold Plus Plan _ as much as $477 a month on average for each Florida patient enrolled.

The newspaper's investigation found that at least 5,440 complaints involving the Gold Plus Plan have been filed with the federal government since June 1987. Reported problems ranged from improper enrollments to failure to provide service.

"I find it fascinating that somehow the overseers can't hold these people to a quality standard of care," Smith said Friday. "I don't know what's going on. It is lack of enforcement of the existing rules and regulations."

Tom Noland, Humana's director of market communications in Louisville, Ky., said the complaints reported in the series represent a small percentage of the plan's members. "Our monthly surveys of members show that the Humana Gold Plus Plan consistently has a satisfaction rating above 90 percent," Noland said.

The plan was cited by the U.S. Health Care Financing Administration twice in 1989 for violating Medicare regulations, including improper denial of claims, enrollment problems and excessive payment delays.

Humana health plans also have prompted 1,628 complaints to the Florida Department of Insurance since 1988, often for bills that the plan did not pay or decisions that left patients harassed by bill collectors.

Humana took over the Gold Plus Plan from International Medical Centers in June 1987.

Smith, who ordered a GAO study of IMC in 1984, said he is worried that many of the patient complaints about IMC appear to be the same as those about Humana's Gold Plus Plan.

"It's bewildering and frustrating that it's happening all over again. We should not let this get as far as what happened with IMC," Smith said.

Shaw said he is concerned about allegations that Gold Plus Plan sales representatives have improperly signed up members.

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