Sometimes the civil court system is a doctor’s best friend. This past Friday, a settlement was announced in a national class action lawsuit brought by state medical associations with the vast majority of the Blue Cross and Blue Shield health plans in the country and the Blue Cross and Blue Shield Association. The settlement calls for a cash payment of $128 million to the class members plus significant changes in business practices that will stop some of the arbitrary reductions in valid claims.
It’s kind of ironic that, led by the medical societies, physicians have had to sue to get the attention of a large organization. Fundamentally, all physicians want is respect – to be treated professionally and ethically when it comes to the business of healthcare. Fee schedules should be provided as a matter of course. A mechanism to quickly and fairly resolve disputes. Stop the arbitrary reduction in the claim, and pay it promptly. Unfortunately, these practices are all too common in business. Slow payment of invoices. Taking discounts, even when not entitled to one. Hidden phone numbers, so customers – you know, the ones who pay the bills – can only talk to some robot in a call center. Many years ago, the Medicare intermediary was holding up claims for a new service, claims that quickly came to $20,000. I finally called the regional administrator for CMS (the HCFA). Two weeks later, after submitting copies of the claims, we got all of our back money and payment rolled in without a hitch after that.
So the good news is that most of the Blues are now legally bound to change. After years of cowering, afraid to ask questions, signing contracts without understanding the terms and fees, and afraid to fight clear and abusive breaches, physicians and other healthcare providers are fighting back – and winning. The attorneys general in several state have brought civil actions as well. Sometimes we need to bring in the grader to level the playing field.
The practice changes that they have agreed to include commitments to do the following:
1. Implement a definition of medical necessity that ensures that patients are entitled to receive medically necessary care as determined by a physician exercising clinically prudent judgment
2. Use clinical guidelines that are based on credible scientific evidence
3. Provide physicians with access to an independent medical necessity external review process;
4. Establish an independent external review board for resolving disputes with physicians concerning many common billing disputes;
5. Pay for the cost of recommended vaccines and injectibles and for the administration of such vaccines and injectibles
6.Not automatically reduce the intensity coding of evaluation and management codes billed for covered services;
7. Ensure the payment of valid clean claims within fifteen (15) days for electronically-submitted claims and thirty (30) days for paper.
8. Provide fee schedules to physicians;
9. Establish a compliance dispute mechanism to address disputes regarding the Blues’ compliance with the agreement;
10. Establish and/or maintain physician advisory committees; and
11. Provide ninety (90) days’ notice of changes in practices and policies and annual changes to fee schedules.
The class action – Love et al. v. Blue Cross Blue Shield Association, et al. – was filed in 2003. The complaint identified numerous Blue Cross and Blue Shield plans as defendants in an alleged scheme to defraud doctors in violation of the federal Racketeer Influenced and Corrupt Organizations Act (RICO). The case is being heard in the United States District Court, Southern District of Florida, Miami Division: 03-21296-CIV-Moreno. Additional background information on the case can be found online at http://www.hmocrisis.com/ and http://www.hmosettlements.com/ . Those sites include complete copies of the Settlement Agreement
This post was partially compiled from press releases.