|
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
|
