FAQs: Blue Cross Blue Shield Class Actions and Settlements

1. What are the legal theories involved in the suit?
Essentially, plaintiff’s counsel argued that every practicing and retired physician in the country has, since 1990, been the victim of a scheme maintained by the defendant payers to defraud and underpay physicians. The suit alleges RICO violations as a result of a conspiracy among payers to defraud and underpay physicians.

2. What is the Blue Cross Blue Shield settlement expected to provide?
The settlement includes about 40 BCBS plans who have set aside a settlement fund of $128 million. There is also substantial prospective relief (new claims payment rules) very similar to those adopted by Anthem/Wellpoint and other payers in their settlements. Practices and hospitals are encouraged to pay close attention to the new payment rules, as they may increase annual physician revenue by 3 percent to 5 percent.

3. How will each practice’s share of the settlement be calculated?
Each eligible physician is entitled to either one, five, or 10 shares from the settlement fund depending on their historic claims payment volume with the BCBS plan or settled payer for the calendar years 2004 through 2006 (three years). Depending on the total number of physicians who file claims, refunds are expected to average about $1,000 per eligible physician.

4. By signing up with MCAG, would our practice's name be disclosed when a settlement is reached?
Practices need not worry about BCBS plans or any other payer identifying them through participation in the settlement. There is no way for the BCBS plan to identify who applies for the funds once the settlement has been reached because disbursement of the refunds is handled through a settlement administrator appointed by and approved by the court. The BCBS plans are setting up a recovery fund ($128 million) and have no interest in finding out which practices recovered from the fund. The fund will be equitably divided among participants and there should be no concern about retribution against practices that do participate.

5. What are the advantages for a practice to sign with MCAG versus waiting for the settlement and filing on its own?
The settlement terms and requirements for collecting the money are very strict and somewhat complex. It is difficult for the practice to recognize when the filing/recovery opportunity begins and ends. The practice would have to receive and understand the notice to class members that is sent by the payer and its counsel. The notice document notifies the class about the settlement and all of the requirements for collecting refunds. It is typically written in legalese and printed in small font. Understanding it at first reading is a daunting task. While it is entirely possible for a practice to use this document to participate, it would take good timing and a dedicated staff to meet all filing deadlines and requirements and to maximize the return available. For example, in two of the last three settlements (Humana and HealthNet), so many practices failed to file claims correctly that the settlement administrators had to notice the class and allow for a re-filing period. Additionally, if a re-file or adjustment to a filing is required, there is a strict, short period (usually about 20 business days) for re-filing; if that opportunity is missed then the refunds for that practice or physician may be reduced or eliminated. 

6. What specific claims information is needed?
Blue Cross Blue Shield paid claims volume over a three-year consecutive period has been the key data requirement. Additionally, the social security or tax ID number and name of the physician and the practice is essential to the filing. In some cases, it has been important to research data bases/billing records and to locate and document certain, specific types of claims for specific years.

7. What specific claims are in question (all or a specific set of codes/diagnosis)?
Physicians/physician groups can aggregate any and all paid claims volume for any product (PPO, HMO, EPO, etc.) with any of the settled Blue Cross Blue Shield plans. Under this settlement, it is not important to segregate claims by CPT codes or combinations of CPT codes.

8. How should practices submit claims?
Most of the practices will be able to submit a simple, electronic file or a claims/payment extract with minimal data requirements (payer ID, date of service, amount billed and amount paid). Paper records are acceptable provided they contain the correct data elements.

9. How are specific contract provisions or patient confidentiality protected?
Your practice or group does not have to have a contract or network arrangement with the settled Blue Cross Blue Shield plan in order to participate in this settlement. Therefore, your payer contract, or lack thereof, is of no consequence in this settlement. Additionally, there is nothing in the settlement that requires disclosure of patient specific health information (PHI). The only important claims data under this settlement is aggregate payment data with Blue Cross Blue Shield plans.

10. How many physicians have joined the suit, and where are they located?
Every practicing physician in the country is eligible for this settlement if they ever billed any of the defendant insurance companies for claims. Sadly, only about 250,000 out of 750,000 (about one third of eligible physicians) active practicing eligible physicians have participated in refunds under the HMO settlements to date. Since these settled payers (CIGNA, Aetna, Anthem/Wellpoint, HealthNet, Humana and Blue Cross Blue Shield plans) conducted business more strongly in some different parts of the country and, in some cases, across the entire country, it is difficult to identify how many physicians participated in each state or region.

11. If my practice/hospital wants to participate, who should I contact?
Should your practice wish to participate in the BCBS settlement as a member of MMS, please call MCAG at (800) 355-0466, or e-mail MCAG at physicianservices@mcaginc.com.

More details on the settlement can be found at www.hmosettlements.com.

Source: Bessler Consulting, Boston