Medical group wins suit against Blue Cross
May 5, 2007
Miami Herald - BY JOHN DORSCHNER
In what could be a precedent-setting verdict affecting 11 other cases around the state, a group of Miami-based pathologists has won a $1.5 million decision against Blue Cross Blue Shield of Florida for nonpayment of services.
The issue was whether the pathologists -- who are medical doctors -- should get paid for their professional services for supervising and analyzing test results, not just for the technical cost of the lab work.
''We respectfully disagree with the court's decision and plan to appeal,'' said BCBSF spokeswoman Valerie Rubin in an e-mail. ``This is an important issue in the ongoing efforts . . . to hold the line on healthcare costs. We will continue to defend against this lawsuit and others like it in order to keep healthcare as affordable and accessible as possible for all Floridians.''
Ervin A. Gonzalez, the pathologists' lead attorney, said their role is crucial in healthcare and needs to be recognized. ``They're the ones that determine if there's an abnormal finding. They're the ones that decide if additional testing is needed. They decide if a consultant should be brought in to study the results.''
In a lawsuit that started in 2005, Gonzalez represents Palmetto Pathology Services, which provides lab testing for patients at Coral Gables and Palmetto General hospitals. Both hospitals are in the network of Health Options, the BCBSF health maintenance organization; the pathologists are not part of the network.
At one time, Health Options paid pathologists for their professional services, then stopped, paying only for the technical part of the lab results, Gonzalez says. Between 2001 and 2004, the pathologists claimed, Health Options cheated them out of $1,149,009.
That money was the ''professional component'' of the doctors' work, including clinical oversight and supervision of the laboratory, assuring the tests are properly performed, directing quality control procedures and other things.
In the case, the pathologists cited state statutes: even though they were out of network, they should still get paid because the in-network hospital was ordering the tests and the HMO was responsible for ``usual, customary and reasonable charges.''
Those charges have become legal dynamite in Florida. Generally, they have come to mean providers' full charges, not the reduced rates given in contracts with private insurers and Medicare. In some lawsuits over out-of-network payments, providers have insisted gross charges are ''customary'' while insurers have paid considerably reduced rates, based on Medicare levels.
Gonzalez said the amount of the charges were not an issue in this case, since Health Options insisted the professional charges weren't justified at all.
The April 20 jury verdict is expected to make for a hard-fought appeal because Gonzalez has 11 other hospital-based pathologists groups from around the state that have cases coming up in front of the same judge, Thomas ''Tam'' Wilson, in Miami-Dade Circuit Court.
