Physicians winning reimbursement fights

Physicians have always battled health plans over reimbursement rates. Often, they feel outgunned by health plans which, despite needing doctors, are the ones who ultimately cut the checks. But of late, the tide may shifting toward physicians, who are increasingly fighting back in court.

For example, physicians settled a major suit targeting 23 Blue Cross and Blue Shield plans [1] this week, winning $128 million over claims that the plans habitually downcoded physician procedures in an effort to save money. Also, this week a court is forcing Blue Cross and Blue Shield of Florida to pay $1.5 million to pathologists [2] who had sued the plan over its refusal to pay for supervision and interpretation of tests.

I don't know if this is actually a trend, or just a swing of the pendulum that favors health plans one year and doctors the next. After all, while the two groups share an interest in protecting patients' health, they're also battling for the same pot of money. (Of course, the two could collaborate to better use the money--which some plans and physicians do--but that's the subject of another column.)

My suspicion, however, is that such cases are getting a more favorable hearing as state and national health reform schemes have taken root. With most schemes depending in part on extending commercial coverage, health plan business strategies are getting a closer look--and doctors are getting a higher-profile stage on which to make the case for better pay. Even if the laws governing such relationships haven't changed, realistically, public awareness does affect how such lawsuits play out.

Of course, this too is probably a passing trend, with scrutiny (and criticism) just as likely to rebound back to physicians. In the mean time, however, this may be a good time for doctors to plead their case--at least in the court of public opinion. - Anne [3]