Doctors Challenge Insurer's Network Blue Cross and Blue Shield Says It's Trying to Keep Members' Fees Low

Article excerpt

Byline: Sarah Skidmore, Times-Union business writer

The slow simmer of physician discontent with Jacksonville-based Blue Cross and Blue Shield of Florida has been heating up.

Insurers are rarely heralded by physicians, but what started as grumblings this spring from Florida physicians has grown into two lawsuits, a state regulatory investigation and the opposition of the state's largest physician group.

These malcontent voices are more than a common gripe; they say that Blue Cross is terminating contracts with physicians irresponsibly -- thereby threatening the patient-physician relationship.

Blue Cross asserts the constant maintenance of its network of physicians is just standard cost-containment practice and says it has to be done to keep premiums low for members. While the insurer admits some terminations have been made, it has kept its total number of available physicians relatively stable in the past two years. Blue Cross said it did not have a complete history of the total number of terminations made in the past three years.

BREWING DISCONTENT

Various groups began grumbling in the spring when Blue Cross made a round of layoffs in its preferred provider organization and health maintenance organization lines. At this point, Blue Cross had dropped about 130 physicians during the year -- several Duval County physicians were included in these terminations. Then a physician in Bradenton brought the issues to a boil for Florida's medical community.

Carlos Mendez, a pediatrician, received a letter terminating his contract after 15 years with the insurer as part of the "periodic re-evaluation."

Mendez said the insurer dropped him because he often made medical decisions that were costing the company too much money.

He often sent patients to specialists that were outside the insurer's network. The physician said he refers patients only to specialists and other physicians he knows and is comfortable with -- people he'd send his family to. But if he stuck to the network Blue Cross has set up, he said, some of his patients would have to go to Tampa for care.

He and his staff encouraged patients experiencing difficultly with claim approval to call the company to complain.

"The squeaky wheel didn't get the grease this time," Mendez lamented.

But it caught other people's attention. In the midst of the spring terminations, the Florida Medical Association caught wind of the situation from many angry members who were terminated or rallying in support behind Mendez.

The FMA issued an alert in June saying the organization was "very alarmed about the orchestrated statewide effort being undertaken by Blue Cross and Blue Shield of Florida to terminate Florida physicians from its various health plans."

In the same month, the FMA sent a letter to the Department of Insurance alerting it of the situation and requesting an investigation of the insurer for "adverse action against a provider" on behalf of Mendez and other terminated physicians.

The Department of Insurance is still investigating under a new provision of the law, instituted only last October, that affirms a physician's ethical responsibility to act on behalf of patients without fear of retribution from insurers. The FMA also complained of Blue Cross violating state laws on unfair competition and deceptive practice, for which it also is being investigated.

Should the department find Blue Cross in violation, the state decides the fate of the insurer. The department said it would be premature to speculate what the outcome would be because the investigation is not complete.

Mendez filed a lawsuit against Blue Cross for the termination of his contract that is still in the courts.

Blue Cross declined to comment on any individual cases.

Mendez said his practice might not ever recoup the losses from the termination, even if he is reinstated. …

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