ATLANTA (CN) – Blue Cross is accused of undercutting payments to cancer doctors in order to make more profit for the insurance company, in ongoing litigation in Fulton County.
The physicians, who operate as Northeast Georgia Cancer Care, dispute a 2007 HMO contract in addition to the 2007 PPO contract and the Participating Physician Agreement at issue in the first complaint.
Both complaints in Fulton County Superior Court accuse the insurance company of reducing reimbursement rates for numerous cancer infusion drugs, services and procedures, arbitrarily and without notice.
The doctors say Blue Cross’s actions are “calculated to maximize its own profits at plaintiffs’ expense without regard to the parties’ contractual obligations or the resulting hardship that defendant’s actions inflict on plaintiffs.” They claim the insurer’s reimbursement practices are a “moving target,” making it difficult to budget or predict payment. The Explanation of Benefits is also difficult to interpret, the physicians noted.
The doctors say they were forced to litigate after Blue Cross failed to respond to a complaint addressing the PPO and PAR contracts filed with the defendant’s Provider Appeals department, according to the initial complaint.
Blue Cross seeks to compel arbitration and to dismiss the complaint or stay proceedings pending arbitration.
Blue Cross “maintains that we have acted appropriately with regards to our policies and procedures,” the company’s public relations director Cheryl Monkhouse said. She added, “Under the terms of their agreement, NEGCC agreed to submit disputes to arbitration as a means of reaching resolution. NEGCC has circumvented this process with the current lawsuit.”
Loretta Goodson, practice administrator with Northeast Georgia Cancer Care, disagrees.
“In our opinion, we followed the policies and procedures in the provider manual for Blue Cross and Blue Shield, and they failed to respond, so we are not required to go to arbitration,” Goodson said.
Goodson said the lawsuit addresses a “pattern of behavior” by Blue Cross. The same parties have a similar lawsuit pending before the Georgia Court of Appeals. This lawsuit, filed in 2007 in Clarke County Superior Court, disputes reimbursement rates for oncology contracts. The dispute led to Northeast Georgia Cancer Care being left out of the HMO network for medical oncology and many cancer patients being forced to drive long distances for care, the physicians say.
“All of this has been very difficult on our practice and our patients,” Goodson said.
Monkhouse said the lawsuit in Fulton County Court should have little effect on the physicians’ practice. “Patient care should not be disrupted while NEGCC pursues their dispute, and we will continue to reimburse the physicians in accordance with their agreements,” Monkhouse said.
The doctors are represented by James W. Boswell with King & Spalding.