Physicians who filed claims in the $131 million settlement of organized medicine's antiracketeering lawsuit against Blue Cross and Blue Shield should receive their checks by mid-August, says Joe R. Whatley Jr., JD, one of the attorneys representing physicians in the lawsuit. Contact the claims administrator , Epiq Systems, if you properly filed a claim and do not receive a check by then, or if the amount is not what you expected.
Former TMA President Bohn Allen, MD, chair of the TMA Board of Trustees' subcommittee negotiating and evaluating the settlement, says the approximate base share amount is around $60. The amount of shares was determined by dividing the amount of the settlement by the number of physicians who filed a claim. Physicians who filed for five shares, for example, will receive about $300; those who claimed 10 shares will receive about $600. Retired physicians will receive around $300. The number of shares a physician can claim depends on the amount of business he or she does with Blue Cross and Blue Shield.
However, the real economic benefit of the settlement to physicians will come in the future, because Blue Cross has agreed to change the way it does business. As a result of the settlement, 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.
Filed in 2003, the 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 for-profit health insurance company in the nation in a prior class action suit. Physicians need to remain vigilant to make sure the companies comply with the terms of the settlements.
Physicians who believe 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 , Aug. 3, 2009