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In 2000, several medical societies brought class action lawsuits against national and regional managed care companies, including Aetna, Anthem, BlueCross Blue Shield Association and independent licensees, CIGNA, Coventry, HealthNet, Humana, PacifiCare, Prudential, UnitedHealthcare and WellPoint on the grounds that the health plans
The class action lawsuits represent over 950,000 physicians who have submitted claims to any of the above named managed care companies. These cases were consolidated in U.S. District Court in Florida and are known as the MultiDistrict Litigation (MDL). A website devoted to the MDL and settlements is at www.hmosettlements.com
The trial began on Sept. 13, 2004 with Aetna and CIGNA having reached settlement agreements prior to its start date. Over the past three years more plans have settled, including HealthNet, CIGNA, WellPoint/Anthem, Humana and Prudential.
Important Dates
Opt-Out-Deadline: Sept. 14, 2007
Claim Submission Deadline: Oct. 19, 2007
Settlement Fairness Hearing: Nov. 14, 2007
The Settlement covers allegations between May 22, 1999 – May 31, 2007 that the Blue Parties, among others, engaged in a conspiracy to improperly deny, delay, and/or reduce payments to physicians, physician groups, and physician organizations by engaging in several types of allegedly improper conduct, including but not limited to:
- Misrepresenting and/or failing to disclose the use of edits to unilaterally “bundle,” “downcode,” and/or reject claims for medically necessary covered services;
- Failing to pay for “medically necessary” services in accordance with member plan documents;
- Failing and/or refusing to recognize CPT® modifiers;
- Concealing and/or misrepresenting the use of improper guidelines and criteria to deny, delay, and/or reduce payment for medically necessary covered services;
- Misrepresenting and/or refusing to disclose applicable fee schedules; and
- Failing to pay claims for medically necessary covered services within the required statutory and/or contractual time periods.
On July 27, 2007 BCBS was required to mail to all network physicians the settlement forms have now been mailed to physicians. Physicians should have received a plain white envelope with a return address referencing the settlement administrators: Blue Parties' Settlement Administrator, PO Box 2876, Portland, Oregon. The settlement forms provide the option of physicians to either opt-in or out of the proposed settlement.
The settlement has been structured into five repayment classifications for physicians:
- Retired or deceased physicians who provided any covered services reimbursed by primary licensees of the BCBSA since May 22, 1999 and who ceased to practice, medicine, or has died as of May 31, 2007
- An actively-practicing physician whose Gross Receipts for the calendar years 2004, 2005 and 2006 for providing Covered Services to the settling Blue Plans’ Plan Members were in the aggregate zero or less than $5,000.
- An Active Physician who is a member of the Settlement Class in John R. Gregg, M.D., et al. v. Independence Blue Cross, et al.; Robert P. Good, M.D. v. Independence Blue Cross, et al.; and Pennsylvania Orthopaedic Society v. Independence Blue Cross, et al. (“IBC Class Action Settlement”), who did not opt out of the IBC Class Action Settlement, and who is relying solely on Gross Receipts for providing Covered Services to IBC Members in order to recover from the Settlement Fund.
- An Active Physician whose Gross Receipts for the calendar years 2004, 2005 and 2006 for providing Covered Services to the settling Blue Plans’ Plan Members were in the aggregate at least $5,000 but less than $50,000.
- An Active Physician whose Gross Receipts for the calendar years 2004, 2005, and 2006 for providing Covered Services to the settling Blue Plans’ Plan Members were in the aggregate $50,000 or greater.
Each class will receive a pro rata portion from the Settlement Fund that has been allocated for retired and the various active types of physicians.
ACC has more documents available for review related to the Settlement:
For more information visit, www.hmosettlement.com or www.bcbsphysiciansettlement.com
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