Blue Cross Compliance Process Announced

Physicians can file a compliance dispute form [ PDF ] if they believe Blue Cross and Blue Shield is not complying with the terms of its settlement of organized medicine's lawsuit against it and other for-profit HMOs. Any physician who did not opt out of the settlement can file a complaint.

In the settlement, which is similar to previous agreements with Aetna, CIGNA, and other defendants, Blue Cross agreed to many reforms. They include agreeing 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 the cost of 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.

Mail the compliance dispute form to Neubert, Pepe & Monteith, PC, 195 Church St., New Haven, CT 06510, or fax it to the firm at (203) 821-2009. 

Deborah J. Winegard, JD, a veteran of the Aetna and CIGNA settlements, has been appointed the compliance dispute facilitator for the Blue Cross lawsuit. You may  e-mail her or call her at (404) 607-8222.

TMA Executive Vice President and Chief Executive Officer Louis J. Goodman, PhD, says TMA supports the process to ensure that all of the HMOs in the lawsuit comply with the settlement terms. Dr. Goodman added that Texas works closely with the Physicians Advocacy Institute (PAI) to ensure fairness for physicians and their patients. He is the PAI treasurer and a member of its board of directors. The settlements created PAI to level the playing field between physicians and health insurers.

Additional information on the lawsuits is on the TMA Web site and at .  


Action , Sept. 15, 2008

Last Updated On

September 30, 2010