Monitor Blue Cross Compliance

It's too late to file a claim, but physicians still need to make sure Blue Cross and Blue Shield (BCBS) continues to honor the terms of its settlement of a 2003 federal class action lawsuit that claimed numerous BCBS plans were involved in a scheme to defraud doctors in violation of the federal Racketeer Influenced and Corrupt Organizations Act (RICO).

Even though it is not formally named in the notice of the settlement that physicians received in 2008, BCBS of Texas is part of the agreement.

The settlement of the lawsuit - Love et al. v. Blue Cross Blue Shield Association, et al. - expires in May 2011, but physicians need to remain vigilant.

BCBS agreed in the settlement that it:

  • 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.

Physicians who believe that BCBS violated its agreements should file a compliance dispute form, says the Physicians Advocacy Institute (PAI), which enforces the settlement on behalf of physicians. The forms are available in the RICO Case Materials section of the TMA website and the Compliance Center of the HMO Settlements website . 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.

TMA will continue to monitor the company's performance in honoring the settlement terms.


Action , June 15, 2010

Last Updated On

April 19, 2012