National Blue Cross Settlement Compliance Process Is Under Way

With final court approval of the Blue Cross Blue Shield (BCBS) national class action settlement (see Vital Signs, September 2007, page 1), the process is now under way to ensure that BCBS fully complies with the “prospective relief” provisions of the agreement. These provisions include a number of physician-favorable changes to BCBS business practices, especially in the area of claims processing. These provisions are detailed on the MMS website at www.massmed.org/ProspectiveRelief.

The most significant benefits for Massachusetts physicians are those not previously addressed by Chapter 141 (the Massachusetts Managed Care Reform Act of 2000) or prior BCBS contracts — namely, an extended claims-submittal period, payment rule and coding disclosures, greater allowances for coding submissions, and tighter recoupment rules.

The national settlement also includes a formal dispute process designed to monitor and enforce BCBS compliance. Physicians who believe that BCBS of Massachusetts has not met those obligations can file a compliance dispute with the compliance dispute facilitator, Deborah J. Winegard, who can be contacted at dwinegard@gmail.com or (404) 607-8222. The process is simple and free of charge. A step-by-step guide and the dispute form are available at www.hmosettlements.com/pages/bluecross.html, and a compliance enforcement toolkit is available at www.hmosettlements.com/pages/compliance.html.

Once the facilitator receives a completed dispute form, she will advise the physician whether, in her opinion, the alleged conduct is a compliance dispute, and whether to prosecute the dispute on the physician’s behalf. The facilitator then works with BCBS to resolve the dispute. Disputes that remain unresolved are referred to a dispute review officer, who conducts a formal legal review. Decisions of the review officer are final, except that some decisions may be appealed to the federal court on limited grounds.

The ultimate measure of success of the business-practice changes mandated by the settlement will depend on actual BCBS compliance with its terms. Physicians can help monitor compliance by filing compliance disputes when they reasonably believe that BCBS has not met its obligations under the settlement agreement.

Compliance disputes must be filed with the compliance dispute facilitator within 90 days of the date the dispute arose or reasonably could be known, whichever is later.

In addition, the MMS has arranged for the Managed Care Advisory Group (MCAG) to assist MMS members, on a discounted basis, with BCBS payment claims during the settlement implementation period, which runs until May 30, 2011. To contact the MCAG, call (800) 355-0466.

– Dean P. Nicastro, Esq.
Pierce & Mandell, P.C., Boston