1 SUMMARY OF THE IBC/AMERIHEALTH/KEYSTONE/QCC (�IBC�) SETTLEMENT I by guym13

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									     SUMMARY OF THE IBC/AMERIHEALTH/KEYSTONE/QCC (“IBC”) SETTLEMENT

I.        IMPACT OF SETTLEMENT

      •        RELEASE

               Ø    THE IBC SETTLEMENT SEEKS A BROAD RELEASE OF CLAIMS
               OF ALL HEALTHCARE PROVIDERS (INCLUDING, AMONG OTHERS,
               PHYSICIANS, CHIROPRACTORS, PODIATRISTS, DENTISTS,
               PHARMACISTS, DME PROVIDERS AND ASSOCIATIONS OF
               PROVIDERS) (NOT INCLUDING HOSPITALS), THROUGHOUT THE
               UNITED STATES FOR ANY AND ALL CLAIMS (BOTH MONETARY AND
               INJUNCTIVE) THAT HAVE BEEN, OR COULD HAVE BEEN, ASSERTED
               AGAINST IBC/AMERIHEALTH/KEYSTONE/QCC SINCE 1993, WITHOUT
               REGARD TO WHETHER THE CLAIMS HAVE ANYTHING TO DO WITH
               THE ALLEGATIONS OF THE COMPLAINT.

      •        TIME PERIOD

               Ø    THE "BENEFITS" OF THE SETTLEMENT (SEE DESCRIPTION
               BELOW) WILL BE PHASED-IN DURING A TWO YEAR PERIOD AND THE
               COSTS OF NOTICE, REPRESENTATIVE PLAINTIFF FEES AND
               ATTORNEYS’ FEES WILL BE FUNDED BY A REDUCTION IN THE
               DURATION OF THE PHASED-IN CHANGES.

               Ø     THUS, ANY "BENEFITS" WILL BE IN EFFECT FOR A PERIOD OF
               LESS THAN TWO YEARS. MOREOVER, THE SCHEDULE MAY BE
               REVISED IF REQUIRED BY IBC’S "BUSINESS REQUIREMENTS."

               Ø     AFTER THE TWO YEAR PERIOD, IBC WILL CONTINUE ITS
               "DISCLOSURE" OBLIGATIONS (SEE DESCRIPTION BELOW), UNLESS IT
               CAN SHOW THAT SUCH DISCLOSURE IS INCONSISTENT WITH ITS
               "BUSINESS REQUIREMENTS" AND, IN ANY EVENT, THE FORM OF
               DISCLOSURE REMAINS WITHIN IBC’S "SOLE DISCRETION."

      •        GAG CLAUSE

               Ø     THE PARTIES TO THE SETTLEMENT HAVE AGREED THAT THEY
               WILL NOT MAKE PUBLIC COMMENTS ON THE SETTLEMENT, EXCEPT
               TO THE EXTENT THAT SUCH STATEMENTS ARE CONSISTENT WITH
               THE JOINT PUBLIC STATEMENT SET FORTH IN EXHIBIT D TO THE
               SETTLEMENT.


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II.        FAILURE TO ADDRESS WRONGFUL PRACTICES

       •        NO CHANGE IN PRACTICES IMPROVING
                PHYSICIAN REIMBURSEMENT IN THE FUTURE

                Ø    THE SETTLEMENT FAILS TO ADDRESS WRONGFUL PRACTICES
                RELATING TO: MEDICAL NECESSITY; REIMBURSEMENT OF CLAIMS
                (SUCH AS AUTOMATIC DOWNCODING AND IMPROPER APPLICATION
                OF GLOBAL PERIODS); FAILURE TO PAY CLAIMS IN A TIMELY
                MANNER; CONTRACTING ISSUES (INCLUDING, AMONG OTHER
                THINGS, UNILATERAL CHANGES TO MATERIAL TERMS OF THE
                CONTRACT AND PROHIBITION ON ALL PRODUCTS CLAUSES); AND
                ADMINISTRATIVE BURDENS. NEVERTHELESS, ALL CLAIMS
                RELATING TO THESE WRONGFUL PRACTICES WILL BE RELEASED.

       •        NO MONETARY RELIEF FOR PAST CLAIMS

                Ø    THE SETTLEMENT FAILS TO PROVIDE ANY MONETARY RELIEF
                FOR PAST CLAIMS. NEVERTHELESS, ALL SUCH CLAIMS WILL BE
                RELEASED.

III.       THE RELIEF IBC CLAIMS TO PROVIDE IS ILLUSORY

                Ø     DESPITE IBC’S CLAIM TO THE CONTRARY, THE SETTLEMENT
                FAILS TO PROVIDE ANY MEANINGFUL RELIEF IN THE AREAS OF
                IMPROPER BUNDLING, FAILURE TO RECOGNIZE MODIFIERS,
                DISCLOSURE OF FEE SCHEDULES AND INADEQUATE APPEALS
                PROCESSES. NEVERTHELESS, ALL CLAIMS RELATING TO THESE
                WRONGFUL PRACTICES WILL BE RELEASED.

       •        IMPROPER BUNDLING AND NON-RECOGNITION OF MODIFIERS

                Ø    ALTHOUGH IBC CLAIMS THAT ITS SETTLEMENT PROVIDES
                RELIEF IN THE FOLLOWING FOUR LIMITED AREAS: "INDEPENDENT
                PROCEDURE BEING REPLACED BY SEPARATE PROCEDURE
                DESIGNATION; "RADIOLOGIC GUIDANCE DURING A PROCEDURE,"
                "MULTIPLE SURGERY REDUCTION;" AND "SPECIFIC MODIFIERS, " IT
                HAS NOT AGREED TO A SET OF CODING RULES TO BE APPLIED TO
                THESE AREAS.

                Ø     IBC ONLY AGREES TO PROCESS CLAIMS IN THESE AREAS IN
                ACCORDANCE WITH "ESTABLISHED STANDARDS" OF ANY ONE OF A
                NUMBER OF GROUPS, INCLUDING ANY "NATIONAL PROFESSIONAL",
                OR "GOVERNMENTAL AUTHORITIES" IT CHOOSES. MOREOVER, THE
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               TERMS “NATIONAL PROFESSIONAL” OR “GOVERNMENTAL
               AUTHORITIES” ARE NOT DEFINED. THUS, EVEN IN THE LIMITED
               AREAS IBC CLAIMS TO ADDRESS, IT HAS NOT AGREED TO
               APPLICATION OF THE AMA CPT GUIDELINES, EVEN THOUGH THE
               AMA CPT GUIDELINES ARE THE THE ONLY RECOGNIZED
               “AUTHORITY” IN THIS AREA.

               Ø    IT SHOULD ALSO BE NOTED THAT, IN THE FIRST OF THE "FOUR
               AREAS" WHICH IBC CLAIMS TO GIVE RELIEF -- "INDEPENDENT
               PROCEDURE BEING REPLACED BY SEPARATE PROCEDURE
               DESIGNATION", -- THE PHRASE “INDEPENDENT PROCEDURE” HAS NO
               MEANING WITHIN CPT. THE SECOND AREA, “RADIOLOGIC
               GUIDANCE DURING A PROCEDURE,” IS NOT DESCRIBED IN
               LANGUAGE SPECIFIC TO CPT CODES AND GUIDELINES.

               Ø    THE THIRD AREA, "MULTIPLE SURGERY REDUCTION," IS A
               SMALL SUBSET OF MULTIPLE PROCEDURE LOGIC AND THE FOURTH
               AREA, "SPECIFIC MODIFIERS," DOES NOT ADDRESS MANY OF THE
               MODIFIERS WITH RESPECT TO WHICH IBC HAS BEEN ACCUSED OF
               IMPROPER PRACTICES.

               Ø    IN ANY EVENT, EVEN IN THESE FOUR AREAS, THE
               AGREEMENT DOES NOT SPECIFY OR BIND IBC TO A PARTICULAR SET
               OF RULES. FOR EXAMPLE, IN THE FOURTH AREA, “SPECIFIC
               MODIFIERS,” IBC LISTS SOME MODIFIERS, BUT FAILS TO PROVIDE
               ANY RULES TO GOVERN RECOGNITION OF SUCH MODIFIERS.
               SIMPLY STATED, IBC HAS NOT MADE ANY COMMITMENT TO APPLY
               CODING RULES BASED ON AMA CPT GUIDELINES IN THE FUTURE.

               Ø    MOREOVER, IF THE STANDARDS IBC HAS CHOSEN TO APPLY
               AND DISCLOSE CHANGE, IBC "RESERVES THE RIGHT TO ADOPT OR
               NOT ADOPT SUCH CHANGES AND WILL DISCLOSE SUCH ADOPTION
               OR NON-ADOPTION."




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     •         "DISCLOSURE" OF FEE SCHEDULES AND POLICIES

               Ø     IBC CLAIMS TO AGREE TO DISCLOSE ITS FEE SCHEDULES, BUT
               FAILS TO INDICATE HOW SUCH FEE SCHEDULES WILL BE
               DISCLOSED.

               Ø     IN ANY EVENT, THE REALITY IS THAT IBC HAS ONLY AGREED
               TO DISCLOSE "THE STANDARD FEE SCHEDULE RELEVANT TO EACH
               PROVIDER’S APPLICABLE SPECIALTIES." THUS, IT APPEARS THAT
               ONLY DISCLOSURE OF STANDARD FEE SCHEDULES PERTAINING TO
               SPECIALTY CODES WILL BE "DISCLOSED."

               Ø     IBC ALSO CLAIMS IT WILL DISCLOSE POLICIES AND
               PROCEDURES THAT “MAY IMPACT PAYMENT A PROVIDER RECEIVES
               FOR SERVICES RENDERED,” BUT DOES NOT INDICATE HOW SUCH
               POLICIES WILL BE DISCLOSED, SPECIFY GUIDELINES AS TO WHAT
               CONSTITUTES ADEQUATE DISCLOSURE, OR DESCRIBE WHAT
               DETAILS WILL BE PROVIDED.

     •         "INQUIRY AND APPEAL PROCESS" FOR PAYMENT DISPUTES

               Ø     UNDER THE SETTLEMENT PHYSICIANS HAVE THE PRIVILEGE
               OF SUBMITTING ANY HMO, POS AND PPO PAYMENT ISSUES
               RELATED TO GENERAL CODING AND CLAIMS PROCESSING ISSUES
               THROUGH TWO LAYERS OF IBC’S INTERNAL REVIEW PROCESSES. IT
               SHOULD BE NOTED THIS PROCESS DOES NOT APPEAR TO APPLY TO
               ALL OF IBC’S PLANS AND PRODUCTS. MOREOVER, THE PROCESS IS
               NOT INDEPENDENT AND THERE IS NO REQUIREMENT THAT THE
               REVIEWER(S) POSSESS ANY DEGREE OF EXPERTISE OR ANY
               CLINICAL EXPERTISE IN THESE MATTERS.




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