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Blues
attempting TRUST contract change
By
MICHAEL SANDLER, MD
MSMS
Board Chair
Dear
Colleagues,
You
may have received a letter from Thomas Simmer, MD (a BCBSM
Senior Vice President and BCBSM's Chief Medical Officer)
stating that your Blue Preferred Plan (TRUST) Program
Professional Provider Agreement (the "TRUST Network
Agreement") is being "revised" to
"clarify" certain terms contained in the TRUST
Network Agreement. This letter states that the amendments to
the TRUST Network Agreement will become effective Dec. 27,
2004. Doctor Simmer's letter is a response to the lawsuit
filed by MSMS and MOA against BCBSM.
The purpose of this communication is to put Doctor Simmer's
letter into context and explain why BCBSM is attempting to
"revise," "clarify," and/or amend the
TRUST Network Agreement.
Why
We Sued BCBSM
All
physicians have the right (just like all other providers of
professional services) to set the fees they charge for their
services. The lawsuit is aimed at preserving each
physician's right to set his or her fees.
The
majority of practicing physicians in Michigan have entered
into a TRUST Network Agreement with BCBSM. Pursuant to the
terms of the TRUST Network Agreement, physicians have agreed
to limit their fees for certain services to those amounts
set forth on a fee schedule that is a part of the TRUST
Network Agreement. The scope of the services for which
physicians must limit their fees to the Fee Schedule Amounts
is the central issue in the lawsuit.
The creation of the new UAW PPOs by General Motors, Ford and
DaimlerChrysler for their UAW member employees is what first
made us aware of this issue. That and the fact that for
years BCBSM has required physicians to improperly limit
their fees to the Fee Schedule Amounts for services provided
to enrollees in certain other PPOs.
The TRUST Network Agreement states that physicians must
limit their fees to the Fee Schedule Amounts for all
"Covered Services." Covered Services as defined in
the TRUST Network Agreement does not mean what most of us
would think it means (i.e., a service the health plan must
provide its enrollees and pay for). Instead, it is defined
simply as any services "cited in" a
"Certificate/Rider/Benefit Plan Description issued by
BCBSM or under its sponsorship..." When MSMS and its
legal counsel examined the details of the UAW PPOs, it was
discovered that physician office services were not cited in
any Certificate/Rider/Benefit Plan Description that had been
issued by BCBSM. The Benefit Plan Descriptions for the UAW
PPOs were issued by each of the auto companies. MSMS took
the position, therefore, that physicians were not obligated
by the TRUST Network Agreement to limit their fees for
office visit services provided to the enrollees in the UAW
PPOs. BCBSM in a July 21, 2004 meeting admitted that it had
not issued any Certificate/Rider/Benefit Plan Description in
connection with the UAW PPOs. BCBSM took the position
instead that it "sponsored" the auto companies'
issuance of the Benefit Plan Descriptions for the UAW PPOs.
BCBSM at this meeting stated that the physician office
services cited in these Benefit Plan Descriptions were
Covered Services as defined by the TRUST Network Agreement
and therefore physicians were obligated to limit their fees
for these services to the Fee Schedule Amounts.
What is BCBSM's basis for its belief that it has sponsored
the issuance of the auto companies' UAW PPO Benefit Plan
Descriptions? Only that BCBSM has entered into contracts
with each of the auto companies to provide the
administrative services necessary to run the UAW PPOs. BCBSM
believes that its status as an independent contractor
providing services to the sponsors (i.e., the auto
companies) of the UAW PPOs makes BCBSM itself the sponsor of
the UAW PPOs. MSMS has since learned that BCBSM has taken
the same position with respect to other PPOs which were
established by an entity other than BCBSM where BCBSM only
provides administrative services to the PPO. The effect of
BCBSM's false interpretation of the word
"sponsorship" in the TRUST Network Agreement is to
wrongfully increase the scope of the definition of Covered
Service in the TRUST Network Agreement, which therefore
increases the number of services that physicians are
obligated to limit their fees to the Fee Schedule Amounts
and ultimately to wrongfully increase the control BCBSM has
over the setting of physician fees in Michigan.
The
lawsuit was filed to enforce the TRUST Network Agreement and
to limit the extent to which BCBSM may control the setting
of physician fees in Michigan to only those services
physicians have agreed to and no more.
In the absence of this lawsuit BCBSM would be free to
administer the health plans established by any employer in
Michigan and to regulate the fees charged by physicians for
their services provided to enrollees in all these health
plans. No physician ever agreed to give such control over
the setting of their fees to BCBSM when they signed the
TRUST Network Agreement.
Why
Is BCBSM Attempting To Amend the TRUST Network Agreement?
BCBSM
has attempted to amend the TRUST Network Agreement to add a
definition of "sponsorship." The TRUST Network
Agreement currently contains no definition of sponsorship.
BCBSM feels it needs to add this definition of sponsorship
because it knows that the TRUST Network Agreement as
currently written does not allow it to control physician
fees for physician office services provided to enrollees in
the UAW PPOs or any other health plan for which BCBSM only
provides administrative services. Doctor Simmer's letter is
an admission that BCBSM's right in the TRUST Network
Agreement to control physician fees does not extend to
physician office services provided to enrollees in the UAW
PPOs or any other physician services provided to an enrollee
in a health plan that BCBSM has an independent contractor
relationship with only pursuant to which it provides
administrative services. BCBSM mailed this letter in
anticipation of MSMS and MOA obtaining the requested
declaratory judgments establishing that the TRUST Network
Agreement does not allow BCBSM to control physician fees for
these services.
BCBSM mistakenly believes that it can unilaterally amend the
TRUST Network Agreement to further obligate physicians to
limit their fees for office visit services provided to
enrollees in the UAW PPOs. Section 6.02 of the TRUST Network
Agreement obligates BCBSM to provide 60 days advance written
notice of a substantial modification to the TRUST Network
Agreement. However, the TRUST Network Agreement does not
state that BCBSM has the unilateral right to modify the
TRUST Network Agreement without the consent of the
physicians and without providing something to the physicians
in consideration of the new obligation (i.e., the obligation
to limit fees for their services they provide to enrollees
in the UAW PPOs to the Fee Schedule Amount) the modification
imposes on the physicians. In the absence of such
consideration and consent, the new obligation would not be
binding on physicians. Permissible BCBSM modifications to
the TRUST Network Agreement made pursuant to Section 6.02
would include only modifications to the TRUST Network
Agreement that do not create additional obligations for
physicians (e.g., adding additional covered services by
BCBSM issuing a Certificate/Rider/Benefit Plan Description,
allowing physicians to also seek payment from an enrollee
directly, expanding the ability of physicians to refer
enrollees to facilities other than TRUST Hospitals,
etc.)."
MSMS
will continue to keep members informed of breaking news
regarding this issue. Be sure to watch Medigram, the MSMS
Web site (www.msms.org), and e-mail for updates. And don't
forget to sign up for the MSMS Payer Solutions Network (PSN),
an e-mail alert system that helps you and your office staff
stay informed of Blues lawsuit updates and other important
payer third party payer news. (To sign up for the PSN, send
your email address and the address of your office manager to
msms@msms.org and type "PSN" in the subject line.)
2004
WCMSSM Children’s Holiday Party Contributors
Dr.
and Mrs. H. Michael Marsh
Jay
K. Moon, MD
N.
Tawile, MD
Dr.
and Mrs. Theodore B. Jones
Drs.
Peter and Alice Watson
Manuel
Tancer and Claire Stroker
Dr.
and Mrs. Renato S. Roxas
H.
Jay & Sandy Zeskind
Dr.
and Mrs. John R. Caldwell
Gregory
L. Barkley, MD
Dorothy
M. Kahkonen
Anne-Mare'
Ice, MD
Mendelson
Orthopedics
Dr.
& Mrs. Agustin Arbulu
Dr.
and Mrs. Mark A. Kelley
Dr.
James Sondheimer
Dr.
and Mrs. George Hill
Benjamin
Reder
Young
J. Kwon, MD
Drs.
Chidi & Bola Arole
WSU
Med School Dean resigns
Dean
John Crissman, MD, stepped down as dean of the School of
Medicine, effective Oct. 15. After a professional leave of
absence he will return to the faculty as a professor of
pathology.
"Dr. Crissman has served the medical school and Wayne
State University well," Provost Barrett wrote.
"During his tenure as dean, he recruited several
outstanding chairs to lead the clinical practices and
established effective collaborative relationships between
the university and medical community. The President, the
Board of Governors, and I are genuinely grateful for his
long service to the University."
In a letter, Dr. Crissman said he is proud to have served
the school and was certain its legacy would continue to
grow.
"I
have had, and continue to have, the greatest respect and
admiration for our faculty. I have never hesitated in my
support of your academic endeavors, or in my personal
mission to foster an environment of research productivity
and excellence," he wrote. "I am proud of the
focus that has come to our research programs over the past
five years: in cancer, maternal and child health,
neurosciences, and urban health. I remain firm in my belief
that a strong research portfolio is a critical component to
our future success, and that focus of our scarce resources
is essential."
A search committee will be formed to find qualified
candidates for Dr. Crissman's successor.
The
search process will be consistent with the contractual
guidelines of the American Association of University
Professors-American Federation of Teachers, which specify
that the search committee consist of elected representatives
of the School of Medicine, representatives of the Detroit
Medical Center and members appointed by the Wayne State
University administration. The School of Medicine Faculty
Senate will be contacted relative to the election of SOM
faculty representatives.
As
the search process moves forward, Provost Barrett will
inform faculty about major developments.
WCMSSM
Alliance
What
We Have Done This Year
-Distribution
of Material to school systems in area. re: Bullying - using
booklets from the AMSA.
Distribution
of Anti-smoking booklets as teaching tool for parents and
teachers to education on the hazards of smoking,
-World
Medical Relief - collection and distribution of medicine and
used glasses that are send to countries in need .
-Partner
with the Wayne County Medical Society to support legislation
that is directly/ indirectly affecting the practice of
medicine.
-Working
with City-Wide Health Expo as a part of the Mayor's Health
Care Initiative - Covering the Uninsured at Ford Field this
past February
-Health
Care Scholarship Program - Scholarships rewarded to three
schools of nursing and one school of medicine.
-Steering
committee for fundraiser to support three local safe houses
for women and children.
-Contributing
food - clothing - hygiene articles and monetary donations to
Interim House
-Volunteers
for the Wayne County Medical Society Foundation Christmas
Party
The
above are but a few of the projects - to continue we need
your support.
Editorial:
What BCBS Is Costing Us
By
JOSEPH WEISS, MD
Editor
At
this time we should focus our efforts on support for the
Detroit Wayne County Public Health Authority. We should be
moving on ways to reconcile the health care needs of
Michigan citizens during a time of Medicaid financial
strain. We should be promoting pharmaceutical drug reform,
and working to fulfill the expectations of the BCBS Provider
Affiliation Strategy. We are distracted.
The
fault lies with Blue Cross/Blue Shield. They imposed on us
an inappropriate transfer of TRUST contracts. We are forced
to bring our case and cause to the courts. BCBS has left us
no other way to respond if we are to meet this challenge to
our independence.
But the courts are not enough. Also, we must turn to the
Michigan Legislature to ban "all products
clauses." That is, we must keep Blue Cross from taking
the future step of placing in front of us a TRUST contract
that says that we must accept not only the TRUST agreement
but any contract Blue Cross develops with anyone.
In addition, we must challenge BCBS in its intent to
arbitrarily fire 700 doctors in its Blue Preferred Plus
plan. BCBS states that the need for "operational
efficiencies" fuels this move. BCBS provides no
evidence to support why the Blues needed to fire 700
physicians from a roster of 4,000. The physicians dropped
could not have all been economic outliers. Taken alone,
statistical analysis of those doctors who were beyond the
mean and its expected deviation would number, approximately
2 percent or no more no more than 80 physicians.
Furthermore, the idea that BCBS has ongoing profiles of all
4, 000 doctors in the network does not stand up to scrutiny.
No physician in Blue Preferred Plus received regular
economic profiling data before being dropped, and no
physician had the opportunity to review any data prior to
being dropped to evaluate its accuracy.
The number of physicians to drop - 700 -- is arbitrary and
capricious. That BCBS action requires a protest by the whole
Medical Society. Furthermore, on behalf of patient care we
must object to this wholesale cut in physician services. To
achieve "operational efficiency," BCBS would have
better served its purposes by identifying the group of
doctors , likely 50 or less, who were excessive in their
charges.
In addition to the above, you will receive a letter from
BCBS informing you that that BCBS has, on its own, altered
the TRUST agreement to fit its current role as intermediary
for the auto health care contracts. By this move, BCBS sees
itself sabotaging the present MSMS lawsuit, and setting up
conditions for future incursions into willful contracts to
control reimbursement. This alteration, which lays a
responsibility on physicians without giving doctors equal
concessions, is illegal. The Michigan State Medical Society
must now go back to the courts and amend its complaint.
MSMS and the county societies must turn all efforts to this
fight with the Blues. The real cost to us is not fees for
our lawyers, but time lost on the important projects noted
in the beginning of this editorial. We must use our limited
resources to counter the actions of BCBS that threaten our
status as professionals.
Unfortunately, we lose the chance to move forward as we are
in a fight just to hold our ground.
Detroit
Wayne County Public Health Authority Update
From
Gail Warden
December
15, 2004
Delegate
Body Meeting and Dinner
6
p.m. at the Hyatt Hotel, Dearborn
MEMBERSHIP
Narendra
N. Khanchandani, MD
Internal
Medicine, Pulmonary Diseases
Medical
School: Topiwala National Medical College 1981
Residency:
Jamaica Hospital 1993-1994, Wayne State University 1994-1996
Office:
4646 John R, Detroit, MI 48201
Ph#
: 313-576-1000
Email:
nkhanch@speakeasy.net
Swhasini
S. Mistry, MD
Psychiatry
Medical
School: B.J. Medical College
Residency:
DPI Detroit 1977-1980, Fairlawn Center 1980-1982
Office:
15645 Farmington, Livonia, MI
48154
Ph
#: 734-425-5320
Email:
smistry@superiorengg.com
William
P. Penn, DO
Family
Practice
Medical
School: Chicago College of Osteopathic Medicine 1960
Residency:
Botsford General Hospital 1969
Office:
9460 Middlebelt, Livonia, MI 48150
Ph#:
734-425-0500
Email:
Pennsail@aol.com
Subhi
Sbahi, MD
Cardiovascular
Diseases
Medical
School: U Aleppo, Fac. Med, Syria
Residency:
Elmhurst Hospital Center-Mt. Sinai, Englewood Hospital
Office:
18303 Ten Mile, Suite 100, Roseville MI
Ph
#: 586-776-8877
Reinstatements
Bassam
Bashowr, MD
Pediatrics
Medical
School: University of Damascus 1967
Residency:
Children's Hospital, University of Michigan Hospitals and
Health Centers, Sinai-Grace Hospital/Grace Hospital
Ph#:
734-523-1050
Residents
Oakwood
Hospital & Medical Center
Hayssam
Fawaz, MD June
2007
Elena
Gupta, MD
July 2006
Amy
Taneja, MD
July 2005
Jeffery
E Zadawa, MD
July 2005
WSU/DMC
Paolo
M Aquino, MD
Krassimir
Denchev, MD
Devangi
Desai, MD
Alejandro
Diez, MD
Haroon
A. Faraz, MD
Rekah
Galla, MD
Edward
Kaminski, MD
Gihan
A. Khair El-Din, MD
Karl
Muendel, MD
Neelima
Penugonda, MD
Latha
Sree Polavaram, MD
Sangeetha
Potu, MD
Hema
M. Vankayala, MD
Medical
Students
Omar
I Ahmad
Wayne
State University
2008
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