Pennsylvania Health Law Lawyer & Attorney : Fox Rothschild LLP : serving Philadelphia, Pittsburgh, Allentown, Erie, Upper Darby Twp

(By William H. Maruca, Esq. - Posted with permission of the Allegheny County Medical Society ) 

A tentative settlement has been reached in a class action brought on behalf of a group of affected physicians against Blue Cross and Blue Shield plans which alleged that the plans engaged in certain misconduct that resulted in the denial or downcoding of physician claims. By now, you may have received a notice from the U.S. District Court for the Southern District of Florida about the proposed settlement of the case, known as Rick Love M.D., et al. v. Blue Cross and Blue Shield Association, et al. The Notice can be found at http://www.highmarkphysiciansettlement.com/documents/I003%20(Notice).pdf and contains detailed information about the suit and settlement.

The Love case started as a national class action which named all of the Blues plans and the national Blue Cross Blue Shield Association, and most of them reached a separate settlement earlier this year. Highmark and its affiliates Keystone Health Plan West, Highmark West Virginia (d/b/a/ Mountain State Blue Cross Blue Shield), and Parker Benefits, Inc. (d/b/a/ Super Blue HMO), have now agreed to similar terms, which are pending final court approval. You may be eligible to participate in both settlements. The settlement establishes a fund of nearly $10 Million and requires the plans to adopt certain business practice reforms to benefit the class of physicians covered in the suit.

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Much to the chagrin of practicing Pennsylvania physicians, the issue of MCare premium subsidies became a political football earlier this month when Governor Ed Rendell said he would not approve the 2008 MCare subsidy until Pennsylvania lawmakers acted on his proposal to expand the state insurance program to uninsured adults.  The proposal calls for using a portion of the MCare surplus to pay for the expanded insurance benefits.  However, according to an article in the Philadelphia Inquirer, Governor Rendell is considering allowing physicians to delay paying their MCare premiums until the debate over the proposed program is resolved and the MCare subsidy legislation is officially extended.  This approach, according to the Governor, likely makes better sense than requiring the premiums to be paid and then later refunding them.  Stay tuned ...  

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The Centers for Medicare and Medicaid Services (CMS) issued a final rule on November 26, 2006 enacting Section 911 of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003. Section 911 of the MMA required the (CMS) to replace the current fiscal intermediary and carrier contracts for the administration of Medicare benefits with new contracts with Medicare Administrative Contractors (MACs) who will administer both Part A and Part B. The duties of the selected MACs will include not only claims processing but also customer service, provider education, financial management, payment safeguards, and information systems security.

Per the final rule, the country will be divided into fifteen “A/B Jurisdictions” and each A/B Jurisdiction will be assigned to one MAC, who will administer both Part A and Part B claims. Pennsylvania, New Jersey, Delaware, Maryland, and the District of Columbia have been assigned to A/B Jurisdiction 12. CMS recently awarded the MAC contract for A/B Jurisdiction 12 to Highmark Medicare Services. Implementation plans for Highmark began in November of 2007 and are expected to be completed by September 2008.  For more infomration on these major changes, contact Anne Jorgensen.

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