EAST LANSING, Mich., Sept. 9 /PRNewswire/ -- The Michigan State Medical Society and the Michigan Osteopathic Association today jointly filed a lawsuit against Blue Cross Blue Shield of Michigan alleging that BCBSM is wrongly fixing the fees physicians charge for office visit services provided to enrollees in the new “preferred provider organization” health care plans for United Auto Workers under the most recent UAW/automaker contracts.
The conduct of BCBSM directly affects more than 10,000 Michigan physicians. The lawsuit is aimed at preventing the potential disruption of health care services to millions of patients with Blue Cross coverage served by these physicians.
Michigan’s doctors are concerned because under the new UAW health care plans, BCBSM deemed a physician office visit a “covered benefit” for UAW members even though it requires a 100 percent co-payment from the UAW member, or the payment of a deductible amount intentionally set so high ($5,000 in the case of DaimlerChrysler) that no patient can reasonably be expected to meet it.
“It really boils down to the simple principle of fairness,” said Detroit radiologist Michael A. Sandler, MD, chair of the MSMS Board of Directors. “We are extremely concerned about what else in the future might be called a ‘covered benefit’ that UAW members or other employee groups will pay 100 percent out of their own pockets and what other physician fees will be unilaterally set by BCBSM. It is not in the best interests of our patients for the automakers and Blue Cross to act in a way that violates generally accepted business practices.”
By calling an office visit a “covered benefit” even though the patient pays 100 percent, BCBSM believed it could require physicians to accept a unilaterally discounted office visit fee based on another physician contract that does not apply to these new “PPOs.” Especially troubling was the fact that BCBSM had indicated that any physician who does not accept the reduced fee would be eliminated from providing health care services to any patient in seven other BCBSM PPO plans, potentially limiting the choice of physicians for millions of Blue Cross subscribers.
“Thousands of Michigan doctors are being affected and health care may be disrupted to a significant number of our patients,” said MOA president-elect Robert J. Stomel, DO, of Farmington Hills. “This ‘PPO’ label is being used falsely since none of the auto companies or BCBSM have contracted with any physicians, hospitals or others to provide the health care services that these so called ‘PPOs’ are supposed to provide to their enrollees. Instead, BCBSM and the auto companies believe they can force physicians to discount their fees without input as to how these arbitrary conditions may affect access of UAW members and their families to physicians of their choice.”
MSMS and MOA are seeking a declaratory judgment from the Ingham County Circuit Court stating that physicians are not obligated to charge the discounted BCBSM fee screen amount for office visit services physicians provide to UAW employees enrolled in one of the new UAW “PPOs.”
Additionally, the complaint seeks a preliminary injunction preventing BCBSM from terminating any of its contracts with a physician based upon that physician’s refusal to charge the discounted fee for these services.
The UAW/automaker collective bargaining negotiations last fall resulted in moving all UAW members previously covered under the Traditional BCBSM Plans into so-called “PPOs” created by BCBSM for each of the auto companies. Legal counsels for the two physician associations argue that BCBSM and the automakers did not create PPOs at all since they did not directly contract with physicians and other health care providers that are necessary to provide the covered services. Instead, they are wrongly relying on existing physician contracts and informing UAW members that their new “PPO” requires physicians to provide office visit services at discounted fee screen rates.
Michigan’s doctors further assert that BCBSM wrongly believed that these existing contracts with physicians (TRUST Network Agreements) obligate physicians to charge the discounted fee rather than the amounts historically charged for office visit services. This interpretation of the TRUST Network Agreements by the auto companies and BCBSM was based on their erroneous conclusion that the benefit plan descriptions for these new plans were issued by BCBSM or under its sponsorship, as required by the TRUST Network Agreements. In addition, BCBSM and the auto companies wrongly believe that an office visit is a “covered service” even though it requires a 100 percent patient co-payment or a deductible that has been set so high that it will never be met. Even though the UAW patient has a 100 percent co-pay, BCBSM still requires physicians to submit a bill for the office visit to Blue Cross despite the fact that BCBSM will provide no reimbursement for that office visit.
Originally, BCBSM officials stated that physicians who did not comply with the office visit discounts would be disaffiliated from the TRUST Network. This would mean that physicians could be disaffiliated from all BCBSM PPO programs in the TRUST Network including Community Blue, Blue Preferred, MI Child, State of Michigan Health Plan PPO, Mental Health Services PPO, MESSA Choices, FEP-PPO, the new DaimlerChrysler Standard Care Network, the new GM Traditional Care Network, and the new Ford National PPO Plan. BCBSM has penalties and other disincentives in place so that patients will be discouraged from seeing an out-of-network provider.
Over the past two weeks during discussions between BCBSM and leaders from MSMS and MOA, Blue Cross proposed changes to address physicians’ concerns. As of September 7, physician leaders and legal counsels from both associations concluded that the proposals provide neither complete solutions nor long-term, enforceable resolutions and determined that filing a lawsuit was necessary.
MSMS is the professional association of 14,500 medical doctors. MOA is the professional association of 4,500 osteopathic physicians.
Michigan State Medical Society; Michigan Osteopathic Association
CONTACT: David Fox of MSMS, +1-517-336-5731; or Heather Picotte of MOA,+1-517-896-5706
Web site: http://www.msms.org/
