AMA to help monitor Blues settlement

Physicians say the move will give them more leverage with the insurer.

By Amy Lynn Sorrel — Posted May 19, 2008

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Physicians have another watchdog in their corner to help ensure the Blues stick to terms of a nationwide settlement over alleged payment abuses.

The American Medical Association recently joined 27 state medical societies to monitor compliance of the class-action agreement reached last year with 900,000 physicians, the Blue Cross Blue Shield Assn. and more than 30 Blues subsidiaries. The plans admitted no wrongdoing.

The AMA's participation came as part of final approval of the $130 million deal on April 19 by Judge Federico A. Moreno in the U.S. District Court for the Southern District of Florida in Miami.

The final provisions, many of which took effect April 21, allow the AMA to help doctors resolve claims disputes and other issues when a settling Blues plan fails to follow the business practice changes it consented to under the deal. Among those terms, the Blues agreed to revise their claims payment and coding procedures, implement medical necessity definitions, disclose fee schedules and ensure prompt reimbursement.

"The transparency and fairness mandated by this settlement will allow physicians to redirect their limited resources from battling for fair payment to caring for patients," AMA President Ron Davis, MD, said in a statement."The AMA stands ready to ensure physicians receive all the protections offered by the national BCBS settlement."

Doctors say the move will give them more leverage with the insurer, one of the nation's largest.

"The prospective relief is so important, and [the AMA's participation] is going to make the [settlement] provisions even more meaningful because the AMA is extremely knowledgeable about the issues impacting doctors," said Edith M. Kallas, the physicians' co-lead counsel.

"What the [state medical societies] have done in the past and continue to do, and what the AMA brings to the table, will make sure doctors get the full benefit of these changes," she said.

Michael A. Pope, a lead attorney representing the settling Blues plans, said the AMA's involvement will help foster better communication with doctors and help both parties "work together to find a way to bring good medical care to the country."

To assist doctors, the AMA created a map identifying which Blues are part of the settlement. Doctors can view the map, along with AMA guidelines regarding enforcement issues, online (link).

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