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KEY TERMS OF THE SUTTER, M.D. v. HORIZON BCBSCLASS ACTION SETTLEMENT; HOW TO LITIGATE &RESOLVE ILLEGAL BUNDLING ISSUESERIC D. KATZ, ESQ.1Monday, November 8, 20101
SUMMARY OF SUTTER/HORIZONSETTLEMENT TERMS Horizon implementing significant business practiceimprovements for New Jersey physicians to: Increase transparency in payment of claims. Reduce administrative overhead. Improve interactions between the health plan andphysicians and help enhance the efficiency and quality ofthe health care delivery system in New Jersey. Sutter class members also receive all of the benefits of theLove v. BCBS Assn settlement including money payments andno automatic downcoding of claims.2Monday, November 8, 20102
Key business reforms in the Sutter Horizon will make complete fee schedules available toparticipating physicians on the provider portal (website); Horizon will disclose the significant automated edits it uses toprocess physician claims and post them on its provider websitethat will allow doctors to know ahead of time which codes will bepaid and/or denied, via an interactive software package known asClear Claim Connect; Horizon will provide 90 days notice to participating physiciansof material changes to its policies, rates and so forth;3Monday, November 8, 20103
Key business reforms in the Sutter Participating primary care physicians will be allowed to closetheir practices to new patients covered by Horizon BCBSNJ; Most fees shall not be reduced for participating physicians, ifat all, more than once a year and Horizon BCBSNJ shallmaintain standard fee schedules within geographic regions; Horizon BCBSNJ agrees not to recover for overpayments tophysicians after more than 18 months of the original paymentand to provide more notice and information regarding anyoverpayments;4Monday, November 8, 20104
Key business reforms in the Sutter A determination of medical necessity by Horizon BCBSNJ shallnot subsequently be revoked absent evidence of fraud, materialerror, or material change in the condition of a patient prior toservice; Horizon will provide detailed monthly capitation reports anda dedicated liaison to address physician inquiries concerningcapitation payments; and Finally, extensive compliance provisions and iron cladenforcement mechanism ensure all business reforms areimplemented correctly and properly followed by the carrier.5Monday, November 8, 20105
Section 7.1 Disclosure of Significant Edits Horizon to post on its provider website, and to update annually, all “SignificantEdits” -- the automated claims processing adjustments made to CPT codes andHCPCS Level II codes submitted by physicians -- that result in a denial orreduction of payment. Automated edits result in difficulty to reconcile payments received with claimssubmitted and to determine whether or not an appropriate payment has been made. Will save significant administrative time. No longer “chasing down” payment onedited claims. Simplify or streamline the services provided and how to best codefor those claims to maximize payment. Horizon will use an interactive software module known as Clear Claim Connect toimplement this benefit. Clear Claim Connect will identify specifically code editrule(s) triggered by submitted claim.6Monday, November 8, 20106
Section 7.2Greater Notice of Policy and Procedure Changes In this provision, Horizon agrees to give 90 days notice to providersof a Material Adverse Change(s) which includes any changes inpolicies, procedures, fee schedules or capitation rates. A physicianshall then have 30 days from the date of the notice to terminate his/her contract.7Monday, November 8, 20107
Section 7.3Section 7.4Capitation Reporting andDedicated Horizon Capitation Liaison Horizon is provides detailed capitation reports that will enable physicians that receivecapitation to ensure that they are getting the money that is due and owing to them andreconcile such payments each month. Horizon establishes an e-mail address for physicians to communicate with dedicatedHorizon capitation professionals directly responsible for resolving common capitationissues and payment inquiries, including, for example: The amount of capitation payment. The timing and manner of assignment of members to a panel. The services that are included in the capitation payment. The correct application of co-payments to evaluation and management or acutecare codes, rather than to “carve out” services.8Monday, November 8, 20108
Section 7.3Section 7.4Capitation Reporting andDedicated Horizon Capitation Liaison The provision also requires Horizon to fully respond to not less than90% of such inquiries within 10 business days. In addition, the liaison will make best efforts to facilitate the promptpayment of any capitation payments due and owing to physicians9Monday, November 8, 20109
Section 7.5Rights of Class Members to Refuse to AcceptHorizon Members Pursuant to this settlement provision, participating primary carephysicians may now close their practices to all new Horizon patientswith 90 days advance notice to Horizon without having to close theirpractices to patients insured by other carriers.10Monday, November 8, 201010
Section 7.6 Availability of Fee Schedules Horizon provides participating physicians “complete fee information showing theapplicable fee schedule amounts.” The provision also requires Horizon to provide not only CPT codes but HCPCS LevelII codes as well. Provision allows a physician to request as many as 100 other codes each year that thephysician actually bills or anticipates billing Horizon. Because Horizon posts complete fee information on its website, physicians will haveimmediate access to their reimbursement rates, and can download thosereimbursement rates into their practice’s management systems for ease of use andreference. These important benefits will enable these Class Members to quickly determineexpected payment for specific services.11Monday, November 8, 201011
Section 7.7 Fee Schedule Changes Horizon will not reduce the fees it pays more than once per calendaryear. If it does, it will be considered a Material Adverse Changeproviding the physician the right to terminate his/her provideragreement. Horizon no longer has a unilateral right to makemultiple fee schedule reductions in a given calendar year.12Monday, November 8, 201012
Section 7.8 Overpayment Recovery Procedures Horizon will not make efforts to recover alleged overpayments 18 monthsafter the payment was received by the physician absent a reasonable beliefof fraud or intentional misconduct. Horizon must provide very specific notice to physicians at least 45 daysbefore engaging in such overpayment recovery efforts and the notice mustinclude: The patient’s name. The service date. The payment amount received by physician. A reasonably specific explanation of the purported overpayment.13Monday, November 8, 201013
Section 7.9 Effect of Horizon’s Confirmation ofMedical NecessityPursuant to this provision of the agreement, Horizon agrees that it will not revokemedical necessity for a pre-approved medical service unless the result of fraud orsignificant error.Section 11(a) Gag Clauses Pursuant to the agreement, Horizon will not limit the free, open and unrestrictedexchange of information between physicians and their patients regarding medicaltreatment and related issues.14Monday, November 8, 201014
Section 9Section 10.2(b)Compliance Reporting andEnforcement Provision Horizon to provide several compliance reports to Class Counsel on an annual basisregarding its implementation and compliance with agreement. Horizon to publicize the business reforms implemented by this settlement so thatphysicians are aware of them and can take advantage of them. Compliance provisionsto require that Horizon develop a means by which physicians can register complaintsif Horizon violates the business reforms. Iron clad enforcement provision that authorizes Class Counsel to go to Court -- onbehalf of individual Class Members or on behalf of the Class and without any cost toindividual doctors -- to enforce any aspect of the agreement.15Monday, November 8, 201015
HOW TO ADDRESS IMPORPERBUNDLING BY CARRIERS First, determine the automated code “edits” used bythe carrier. This can be accomplished from variousinformation sources. These sources include editing software, edit lists,provider bulletins, manuals, claims data, etc.16Monday, November 8, 201016
HOW TO ADDRESS IMPORPERBUNDLING BY CARRIERS Compile edits into a list. Use coding expert and/orprofessional practitioner with similar expertise toreview for adherence to CPT and HCPCS codingprinciples, guidelines, and conventions as well asMedicare/CMS. Code edits will be “disputed” ifthey violate of CPT, HCPCS, specialty society orother objective coding criteria. “Final” edit list, with all disputed edits, thenreviewed by a health economist to calculatedamages using carrier’s claims data and applicablefee schedules.17Monday, November 8, 201017
OTHER MANAGED CARE BILLING CLASSACTIONS INVOLVING ATTORNEY ERIC KATZKirsch, D.D.S. v. Horizon I (prompt payment)Kirsch, D.D.S. v. Horizon II (bundling, downcoding,modiRiers, failure to pay according to fee schedule)Sutter, M.D. v. Oxford Health Plans (prompt payment,bundling, downcoding, modiRiers)Kirsch, D.D.S. v. Delta Dental (prompt payment, bundling,downcoding, failure to pay ancillary services)Class Actions v. Individual Lawsuits – which isbetter?18Monday, November 8, 201018
USE OF ATTORNEYS INCOLLECTION AND BILLING Why you should consider using an attorney Exhaust all your efforts 0irst before hiring an attorney Bene0its of having an attorney Legal issues are “tough” to deal with, signi0icant and expensive expertsrequire, and providers are in business of rendering care, not trackingdown claim payments and enforcing their rights Carrier “knows you mean business” Attorney often have “decision maker” contacts that cut to the chaseand resolve the issue more quickly and favorably on behalf of theprovider19Monday, November 8, 201019
USE OF ATTORNEYS INCOLLECTION AND BILLING Why you should consider not using an attorney Cost to provider (provider should request a contingencyarrangement so the attorney is only paid if there is a recovery)Minimal risk of being viewed as “troublemaker”20Monday, November 8, 201020
QUESTIONS?PLEASE DON’T HESITATE TO CALL ME ANYTIME!ERIC D. KATZ, ESQ.MAZIE SLATER KATZ & FREEMAN, LLC103 Eisenhower ParkwayRoseland, New Jersey 07068(973) 228 9898(973) 228 0303 Faxwww.provideradvocate.comwww.njlawyer [email protected], November 8, 201021
Improve interactions between the health plan and physicians and help enhance the efficiency and quality of the health care delivery system in New Jersey. Sutter class members also receive all of the benefits of the Love v. BCBS Assn settlement including money payments and no a
