NCMS Summary of Complaint Against BCBSNC

Summary of Complaint

North Carolina Medical Society vs. Blue Cross Blue Shield North Carolina

>BCBSNC has engaged in numerous unfair and deceptive acts and practices designed to delay, deny, impede and reduce lawful reimbursement to NCMS physicians who are participating physicians in its networks.

> As a result of the extraordinarily unequal bargaining positions between physicians and BCBSNC, and the physicians? reliance on BCBSNC to provide access to significant portions of their patient base, BCBSNC has been able to force physicians to enter into one-sided contracts that infringe upon the doctor-patient relationship and threaten continuity of care.

> BCBSNC has employed a variety of means to effect their improper and deceptive scheme, such as:


1. BCBSNC systematically denies reimbursement to NCMS members for medically necessary services by bundling; downcoding; failing to appropriately recognize modifiers; and otherwise routinely and unjustifiably refusing to pay for treatments by physicians.



2. BCBSNC systematically denies payment to NCMS members for medically necessary claims without regard for individual patients' medical needs by improperly employing software programs to automatically downcode procedures and/or deny payment to physicians without appropriate clinical review, oversight or justification; and improperly applying so-called ?medical policies or guidelines? for the purpose of denying payment for coverage of medically necessary treatments.



3. BCBSNC fails to provide adequate staffing, staff training, or staff supervision to handle physician inquiries. In this regard, BCBSNC has created and maintains an inefficient administrative system designed to frustrate payment to NCMS members by requiring physician offices to make excessive telephone inquiries to obtain proper reimbursement of claims and to resolve contractual or payment disputes. BCBSNC routinely and unjustifiably fails to make payments to NCMS members within the time period prescribed by applicable provisions of North Carolina State law, requires redundant and excessive requests for medical records and erects other administrative barriers to delay such payments. BCBSNC fails to provide sufficient explanation for its payment denials and reductions.



4. BCBSNC has established a method wherein physicians can telephonically or electronically verify the eligibility of patients for coverage, but routinely refuses to honor these eligibility verifications and retroactively denies claims or seeks refunds of claims for payment made in reliance on these eligibility verifications.



5. BCBSNC frequently and unreasonably demands refunds or recoupments of ?overpayments? of claims previously paid, even when the overpayment was based on BCBSNC?s errors or other circumstances beyond the physician?s control such as eligibility or the existence of other primary insurance by enrollee of which BCBSNC has or should have knowledge. If physician declines to refund monies to BCBSNC, such ?overpayments? are automatically deducted from current claims, leaving NCMS members with little or no recourse.



6. BCBSNC has established a complex, bureaucratic and time-consuming appeals process for enrollee and physician disputes related to medical necessity, benefit coverage and claims payments which discourages both patients and physicians from pursuing legitimate appeals.



7. In particular, BCBSNC requires physicians to obtain written permission for payment- related appeals, even when the patient has no direct relationship with the physician or no financial interest in the outcome of the appeal.



8. BCBSNC engages in a practice wherein it requires physicians to participate in all or none of its product lines, referred to as "all products" requirements. This practice occurs by declining to contract with physicians or terminating physicians who do not wish to participate in all BCBSNC products.



9. BCBSNC has terminated its benefits "predetermination" program, wherein physicians could obtain a coverage decision prior to rendering a service. This leaves physicians and patients without certain advance knowledge as to whether payment will be forthcoming for expensive surgeries and other procedures and services.



10. BCBSNC periodically requires physicians to sign "confidentiality agreements" prior to making payment for disputed claims. If physicians then disclose such payments to other physicians, the BCBSNC confidentiality agreement expressly provides that they will forfeit such payments.

Print Page