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On April 27, 2007, counsel representing a putative class of approximately 900,000 physicians, as well as the medical societies of numerous states and other medical societies across the country, announced that they had settled a national class action lawsuit pending before U.S. District Judge Federico Moreno in federal court for the Southern District of Florida in Miami.
The class action, Love et al. v. Blue Cross Blue Shield Association, et al., named numerous Blue Cross and Blue Shield plans as co-conspirators in a massive scheme to defraud doctors in violation of the federal Racketeer Influenced and Corrupt Organization Act (RICO).
Hawaii Medical Service Association (HMSA), the largest health insurer in Hawaii, is a member of the Blue Cross and Blue Shield Association. The Hawaii Medical Association (HMA) is a plaintiff in the case.
Compliance Disputes
Physician Advisory Committee
Settlement Terms
Settlement Press Release
Compliance Disputes
The Physicians Advocacy Institute, Inc. recently appointed a Class Compliance Dispute Facilitator, and the Compliance Dispute Program contained in the Blue Cross Blue Shield Association Settlement Agreement is now underway. Physicians (who did not opt out of the settlement) who believe that any of the settling Blues plan/s has violated the Settlement Agreement may file Compliance Disputes.
Press Release
Compliance Program Overview
Compliance Dispute Process
Compliance Dispute Form
HMA members have the benefit of HMA representation for the enforcement of settlement terms. HMA will report systemic issues and violations of settlement terms to the Compliance Facilitator. To report violations, contact Hawaii Medical Association:
April Donahue
Executive Director
1360 Beretania Street #200
Honolulu, HI 96814
Phone: (808) 536-7702
Fax: (808) 528-2376
Non-member physicians may visit www.hmosettlements.com to find the forms necessary to file a dispute or contact the Class Compliance Dispute Facilitator, Deborah J. Winegard, phone: 404-607-8222. Compliance dispute forms may mailed to Neubert, Pepe & Monteith, PC, 195 Church Street, New Haven, CT 06510 or faxed to the above law firm at (203) 821-2009. See "How to File a Dispute".
Please Note: Although compliance disputes must generally be brought within 90 days after the compliance dispute first arose or could reasonably have been known (whichever is later), the compliance process has been held into abeyance until now. Therefore, physicians may raise compliance disputes that arose at any time after a Blue Party was required to implement its obligations under the Settlement Agreement. Many of these became mandatory on the Final Order Date, April 21, 2008. Some obligations became effective on the Preliminary Order Date, May 30, 2007. For a complete list of the start dates for the settlement's provisions, please refer to www.hmosettlements.com.
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Physician Advisory Committee
One of the important terms of the Blue Cross Blue Shield settlement is the creation of a Physician Advisory Committee. The purpose of the Physician Advisory Committee is to:
“…discuss issues arising from or related to the relationships and interactions between and among Physicians, their patients, and the Blue Plan. These issues may include, but are not limited to: (a) improvement of health care and clinical quality; (b) improvement of communications, relations and cooperation between Physicians and the Blue Plan; and/or (c) matters of a clinical or administrative nature that impact the interaction between Physicians and the Blue Plan.”
The settlement allows HMA to appoint four of the twelve members of the Physician Advisory Committee, based on criteria specified by the settlement agreement.
BCBS Settlement Physicians’ Advisory Committee – HMA Appointees
- Herbert KW Chinn, MD
- Melvin Inamasu, MD
- Gerald McKenna, MD
- Michon Morita, MD
BCBS Settlement Physicians’ Advisory Committee – HMA Members Appointed by HMSA
- Anne Biedel, MD
- Patricia Lanoie Blanchette, MD
- Bernard Fong, MD
You are encouraged to contact HMA with any issues the committee may need to discuss.
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Overview
As of April 21, 2009, all the provisions in the Blue Cross Blue Shield Settlement Agreement have taken effect. This means that settling Blue Cross Blue Shield plans:
- May not seek overpayment recovery beyond 18 months
- Must use a clinically based definition of medical necessity
- Must adhere to most CPT© coding rules including payment for E&M codes appended with a 25 modifier and payment for add-on codes
- Must provide 90 days advance notice of material adverse change
- May not require physicians to participate in all products
- Must disclose their methodology for determining UCR amounts
H_ § 7.13(a) Credentialing
The Blue Plan Hawaii Medical Service Association (hereinafter as used in this Exhibit H "HMSA") is subject to the following amendment to the second sentence of § 7.13(a):
HMSA shall complete primary source verification and notify the Physician as to whether he or she is credentialed within thirty-five (35) days of receiving a Physician’s completed application to be a Participating Physician unless in spite of HMSA’s best efforts and because of a failure of a third party to provide necessary documentation, HMSA cannot obtain the necessary information to make a decision within thirty-five (35) days. The thirty-five day period shall be tolled for: 1) any time period HMSA is waiting on information from the Physician; and 2) the time period primary source verification is pending with CVS.
H __ § 7.22 Overpayment Recovery Procedures
(c) HMSA shall comply with the obligations under § 7.22 except with respect to the time limit for Overpayment recovery efforts for claims that are paid under a Plan that are later determined to be the responsibility of a workers compensation carrier. For claims that are determined to be the responsibility of a workers compensation carrier, HMSA shall have four years after the payment was received by the Physician to recover from the Physician the difference between what the Physician was paid by HMSA for the claim and the amount the claim is determined to be payable under workers compensation.
(d) HMSA will satisfy the notice requirements of § 7.22 for Medicare cross over claims and Medigap claims by providing on the Report to Provider (i) the patient’s name; (ii) claim identification number (iii) the service date; (iv) the payment amount received by Physician; and (v) a reasonably specific explanation of the change (including the procedure code, where appropriate).
H __ § 7.29(c)(ii)(F) Arbitration
(e) HMSA may require arbitration proceedings to occur in Honolulu, Hawaii. Physicians who have an office on an island other than Oahu may, at the physician’s election, participate in arbitrations by telephone or in person.
H __ § 7.30 Compliance with State Law and Applicable Government Contracts
(f) HMSA shall not be required to comply with the obligations under § 7 with respect to the QUEST program. HMSA agrees that for the QUEST program:
1. HMSA shall comply with § 7.13(b) and will not require a Participating Physician to participate in the QUEST program in order to participate in Product Networks in which such Participating Physician is compensated on a fee for service basis; and
2. HMSA shall comply with § 7.20 solely by utilizing Medicare CCI Edits in processing QUEST claims and the CCI Edits are the sole system of Edits applied to such claims.
H__HMSA – 65C Plus Program
This provision clarifies that HMSA's provision of Medicare part B services under its 65C Plus program is included within the exemption of 7.30(a) for a Blue Party's role as a carrier providing administrative services for Medicare Part B business.
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