Roseland, NJ (PRWEB) October 20, 2006
On October 16, 2006, Horizon Blue Cross Blue Shield of New Jersey and Eric D. Katz, counsel for the plaintiff physician class, in John Ivan Sutter, M.D. et al. v. Horizon Blue Cross Blue Shield of New Jersey (L-3685-02), announced that they have agreed to resolve the class action lawsuit pending before Judge Stephen Bernstein in New Jersey Superior Court, Essex County on mutually beneficial terms. If the court approves the settlement, the agreement will conclude the lawsuit against Horizon BCBSNJ.
Under the settlement agreement, Horizon BCBSNJ has committed to continue significant business practice improvements related to physicians to increase transparency in payment of claims, reduce administrative overhead, and improve interactions between the health plan and physicians. These improvements will help enhance the efficiency and quality of the health care delivery system in New Jersey.
Key settlement agreement points include:
- Horizon BCBSNJ will make fee schedules for commonly used procedures available to participating physicians by CD-ROM or electronically;
- Horizon BCBSNJ will disclose the significant automated edits it uses to process physician claims;
- Horizon BCBSNJ will provide 90 days notice to participating physicians of material changes to its contracts, policies, and procedures;
- Participating primary care physicians will be allowed to close their practices to new patients covered by Horizon BCBSNJ;
- Most fees shall not be reduced for participating physicians, if at all, more than once a year and Horizon BCBSNJ shall maintain standard fee schedules within geographic regions;
- Horizon BCBSNJ agrees not to recover for overpayments to physicians after more than 18 months of the original payment and to provide more notice and information regarding any overpayments;
- A determination of medical necessity by Horizon BCBSNJ shall not subsequently be revoked absent evidence of fraud, material error, or material change in the condition of a patient prior to service;
- Horizon will provide detailed monthly capitation reports and a dedicated liaison to address physician inquiries concerning capitation payments.
Katz is a partner in the Roseland, New Jersey law firm of Mazie Slater Katz & Freeman, LLP.