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See You in Court


Legal action to urge clarity in payer fee schedules

The most fundamental aspect of your business -- how much and when you get paid for treating patients -- may be changing.

In a lawsuit now being heard in Florida, a group of medical societies is arguing that insurance companies conspire to cheat doctors out of well-deserved fees. It's one in a series of claims that the Medical Association of Georgia and other medical associations around the country are pursuing, according to David Cook, MAG's executive director and general counsel.

If Cook wins, it wouldn't be the first time he beat managed care in court. As a result of earlier legal victories, Blue Cross Blue Shield of Georgia is now doing something that few, if any, insurance companies do: telling physicians how much they will pay them.

What a novel concept.

Federal and state laws that prohibit physicians and practices from sharing fee information are based on outmoded assumptions about the bargaining position of physicians and the need to protect the public. But courts -- not Congress or state legislatures -- are slowly recognizing that those assumptions must change.

So while recent court rulings against the Georgia Blues may alter the relationship between physicians and insurers, Cook and counterparts from California, Florida, Texas, and other state associations want to go further. And they are, as the impetus behind the Florida federal civil suit.

Their claim? That software used by insurers to verify medical claims is automatically and improperly lowering reimbursements. According to Cook, if the medical societies are victorious, their spoils would include penalties paid by the insurance industry totaling $2 to $3 billion -- which is "nothing compared to what they've taken illegally from physicians," he contends.

The size of the payback aside, this is an ongoing attempt by state medical societies to alter the professional lives of physicians. It's much needed. When it comes to physicians, I cannot think of another group of professionals who train as long, dedicate as much, and are forced to cede such control over the execution of their professional duties. Lawyers, frankly, would not stand for it. And physicians shouldn't have to.

Ultimately, Cook and medical societies around the country are trying to fundamentally shift the balance of power between physicians and insurers. The progress they've made is palpable -- but they still have a way to go. As one physician proponent puts it, "We're down to the third-yard line; we just need to get the ball over the goal. Physicians will then get a very, very big win."

What can you do to be a part of it? Find out if your state medical society is involved in these pending legal actions. If you're not a member of your society, consider joining. The few hundred dollars in annual dues is a small investment compared to the reward of changing the way you practice medicine and how you are compensated for the care for your patients.

Politics and Your Practice is written by Ken Karpay, JD, CMC, associate publisher of Physicians Practice and a management consultant. He can be reached at kkarpay@physicianspractice.com.

This article originally appeared in the May 2003 issue of Physicians Practice.



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