The final appeal surrounding the settlement of the antiracketeering lawsuit against the Blue Cross and Blue Shield plans and the Blue Cross and Blue Shield Association have been resolved and the more than $130 million in settlement funds will be distributed this summer, says Texas Medical Association General Counsel Donald P. Wilcox, JD.
The deadline for physicians to file a claim has passed.
Filed in 2003, the class action lawsuit - Love et al. v. Blue Cross Blue Shield Association, et al. - 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).
Physicians and medical societies have previously settled very similar claims against almost every other managed care insurer in the nation in a prior class action, resulting in major reforms in the health insurance landscape in this country.
As a result, Blue Cross and Blue Shield plans:
- May not seek overpayment recovery beyond 18 months (six months for insured plans) unless fraud is implicated;
- Must use a clinically based definition of medical necessity;
- Must adhere to most CPT coding rules, including payment for evaluation and management codes appended with modifier 25 and payment for add-on codes;
- Must provide 90 days advance notice of material adverse changes;
- May not require physicians to participate in all products, and
- Must disclose their methodology for determining "usual, customary, and reasonable" amounts.
Blue Cross and Blue Shield is one of many health insurers that agreed to change their business practices because of organized medicine's legal action. However, physicians need to remain vigilant to make sure the companies comply with the terms of the settlements.
Physicians who believe Anthem/WellPoint (UniCare), Health Net, Humana, and Blue Cross and Blue Shield have violated their settlement agreements should file a compliance dispute form, says the Physicians Advocacy Institute (PAI), which enforces the settlements on behalf of physicians. The forms are available in the RICO Case Materials section of the TMA Web site and the Compliance Center of the HMO Settlements Web site . There is no cost to file a dispute. TMA helped create PAI and is an active member, assisting in enforcement of the settlements.
The TMA Hassle Factor Log program, as well as the TMA Office of the General Counsel , also can help.
Action , June 16, 2009