Physicians will soon begin receiving official notice of the settlement ( PDF ) of the federal antiracketeering lawsuit against Blue Cross and Blue Shield, along with instructions on how to file a claim for past harm. Claims must be filed by Oct. 19.
The settlement, announced April 27, includes substantial prospective relief as well as a guaranteed cash payment of more than $131 million to physicians who qualify and file a claim. All practicing Texas physicians can benefit from the approximately $131 million settlement, receiving prospective relief from changes to Blue Cross practices, and, if they file a claim, retrospective relief for past harm, even if they never did business with Blue Cross.
In filing out the claim form, note that Blue Cross Blue Shield of Texas is included in the settlement under Health Care Service Corporation (HCSC). Payments from BCBS of Texas count in the computations under Section C of the claim document.
Physicians who want to opt out of the settlement must do so by Sept. 14.
Physicians also have the option of donating their share of the settlement to the Texas Medical Association Foundation. TMA Foundation is the philanthropic, 501 (c)(3) arm of Texas Medical Association. It's purpose is to attract donations in support of TMA's ambitious health improvement initiatives such as Hard Hats for Little Heads and Be Wise -- immunize. TMA Foundation also supports TMA county medical society and alliance and medical student chapter community health and education programs. Gifts to TMAF are tax deductible to the full extent permitted by law. Go to www.tmaf.org for more information.
More than 90 percent of Blue Cross and Blue Shield health plans and the Blue Cross and Blue Shield Association are involved in the settlement.
Although Blue Cross denies any wrongdoing, it did agree to change its business practices. In the settlement, which is similar to previous agreements with Aetna, CIGNA, and other defendants, Blue Cross agreed to:
- Ensure the payment of valid, clean electronic claims within 15 days and paper claims within 30 days;
- Provide fee schedules to physicians;
- Implement a definition of medical necessity that makes sure patients are entitled to receive medically necessary care as determined by a physician exercising clinically prudent judgment in accordance with generally accepted standards of medical practice;
- Provide physicians with access to an independent medical necessity external review process;
- Use clinical guidelines based on credible scientific evidence published in peer-reviewed medical literature (taking into account physician specialty society recommendations, the views of physicians practicing in the relevant clinical areas, and other relevant factors) when making medical necessity determinations;
- Establish an independent external review board for resolving disputes with physicians concerning many common billing disputes;
- Pay for the cost of recommended vaccines and injectibles and for administering them;
- Not automatically reduce the intensity coding of evaluation and management codes billed for covered services;
- Establish a compliance dispute mechanism to address disputes regarding the Blues' compliance with the agreement; and,
- Establish and/or maintain physician advisory committees.
TMA was involved in the case, including the settlement negotiations, but not as a formal plaintiff. The Connecticut State Medical Association was the state medical society plaintiff, along with several physicians. TMA was a formal party in the suit in the original class action suit against the other 10 major carriers and signed the Blue Cross and Blue Shield of Texas settlement.
More information about the Blue Cross settlement and settlements with the other for-profit HMOs named in the lawsuit can be found at www.texmed.org/rico or www.hmosettlements.com , or by calling the settlement administrator at (877) 893-2643.