A judge approved the regulation of $ 2.8 billion in BCBS. Why some suppliers undress

After more than a decade, a judge approved a historic regulation of collective appeal of $ 2.8 billion involving Blue Cross Blue Shield – but for some suppliers, that was not enough.

The regulations were to resolve a legal action brought in 2012, in which providers and hospitals said that Blue Cross and its affiliated plans had underpaid them. Providers allegedly alleged that Blue Cross had violated antitrust laws by dividing the United States into “service zones” and agreeing not to compete in these areas. They also argued that the insurer set the prices of his services.

In other words, the complainants allegedly alleged that Blue Cross has deflated the reimbursements by ending in different states to pay more than a certain amount for the services, said Guillermo Beades, partner of the Frier Levitt health litigation service.

The regulation of $ 2.8 billion will be divided between approximately 3 million members of the collective appeal. This is the largest regulation for an antitrust case of health care.

The insurer said in a statement to Medcity News that he was “satisfied with the court order approving the regulations we have reached to resolve complaints in this case”.

While Blue Cross Blue Shield is satisfied with the colony, many providers are not. About 6,500 suppliers withdrew from the regulations. Dozens have also brought their own lawsuits against the insurer, including major health systems such as Providence, Commonspirit Health, Wellspan and Bon Secours Mercy Health.

A spokesperson for Providence told Medcity News that he had decided to withdraw from the colony because he did not reflect the extent of the anti-competitive damage that the system suffered by Blue Cross.

“We are looking for separate individual allegations because our estimated damage is numerous, much higher than what has been offered under the class regulations and we want to end all the anti-competitive and harmful blues practices,” said the spokesperson who refused to be appointed.

Medcity News contacted many other health systems, which refused to comment or did not respond.

The colony

The regulation of $ 2.8 billion was approved by chief judge of the American district R. David Proctor in Alabama. In addition to payment to members of the collective appeal, the regulations also require injunctive compensation to resolve the problems of suppliers who have “been at the heart of this dispute,” said the judge’s decision.

For example, it requires changes to the Bluecard system, which allows members of a Cross Blue plan to receive health services when you travel or live in another Blue Cross Plan area. Providers must submit complaints via the Bluecard system when treating members of another cross Blue plan.

“For decades, providers have complained that, despite his positive points, Bluecard is a non -transparent program that causes additional costs, ineffectures and frustration,” said the judge. “The injunctive relief of the settlement agreement will considerably improve the experience of providers with the Bluecard system, will bring more transparency and efficiency and will result in a responsibility for the blue plan.”

Some of the BlueCard program changes include the creation of a cloud -based system that provides better access to the benefits of members and eligibility verification information and pre -authorization requirements. It also requires that each blue plan can pay clean (which means without errors), complaints fully assured within 30 days and appoint a dedicated BlueCard executive responsible for the supervision of program operations.

In addition, suppliers will have more possibilities to conclude value -based contracts with Blue Cross plans, according to the decision.

To guarantee compliance, a surveillance committee will also oversee the implementation of the settlement agreement for five years. The Committee will examine the new rules proposed by Blue Cross and will solve the disputes linked to the conditions of the regulation.

Why suppliers undress

In nominal value, a regulation of $ 2.8 billion may seem a lot of money.

But for health systems dealing with hundreds of billions of dollars in annual income, “it is a drop in the bucket”, according to Beades de Frier Levitt.

“First of all, you have to pay legal costs,” he said. “And then in addition to that, you have an equal share. It is not pro rata, it is equal between the 3 million participants. So, if you opt, you will not get as much money. And if you are a large group that has millions of dollars of complaints that have been underpaid, it will not work to your advantage.”

Beades added that there is also dissatisfaction with the non -monetary terms of the regulations. Some providers do not consider that these reforms go far enough to change the structure that allowed anti -competitive behavior in the first place.

In the end, providers want more transparency, said Beades.

“They want to know that there are enough checks and counterweights in place so that it does not happen again, because if you look at the history dispute against the major systems – Unitedhealthcare, Horizon – like all five to 10 years, you will see one of them being dropped for hundreds of millions to a billion dollars like here,” he said. “And that does not prevent them. They will amount to doing what they did five to eight years later.”

Providence, on the other hand, wants fair compensation for the reprehensible acts of Blue Cross, including “the underside and restrictions that have had an impact on Providence capacity to provide effectively and competitive care and continue to provide critical services to poorly served communities,” said the spokesperson.

The health system wishes to keep the insurer responsible and receive a resolution which “reflects the actual extent of the damage that our organization and the communities we serve have suffered,” added the spokesperson.

In the complaint filed by several health systems in March, the complainants called for definitively prohibiting blues plans from concluding agreements that fix prices or damage to competition. They also want to receive damages in “three times the amount of damages suffered by the complainants”.

Photo: Valerii Evlakhov, Getty Images