Medical Society v. AMERIHEALTH HMO

868 A.2d 1162, 376 N.J. Super. 48
CourtNew Jersey Superior Court Appellate Division
DecidedMarch 16, 2005
StatusPublished
Cited by17 cases

This text of 868 A.2d 1162 (Medical Society v. AMERIHEALTH HMO) is published on Counsel Stack Legal Research, covering New Jersey Superior Court Appellate Division primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Medical Society v. AMERIHEALTH HMO, 868 A.2d 1162, 376 N.J. Super. 48 (N.J. Ct. App. 2005).

Opinion

868 A.2d 1162 (2005)
376 N.J. Super. 48

MEDICAL SOCIETY OF NEW JERSEY, Plaintiff-Appellant,
v.
AMERIHEALTH HMO, INC. and Independence Blue Cross, Defendants-Respondents.

Superior Court of New Jersey, Appellate Division.

Argued January 4, 2005.
Decided March 16, 2005.

*1163 Edith M. Kallas, New York City (Milberg, Weiss, Bershad, Hynes & Lerach) of the New York Bar, admitted pro hac vice, argued the cause for appellant (Lite, DePalma, Greenberg & Rivas, and Ms. Kallas attorneys; Allyn Z. Lite and Ms. Kallas, on the brief).

David L. Comerford, Philadelphia (Akin, Gump, Strauss, Hauer & Feld) of the Pennsylvania Bar, admitted pro hac vice, argued the cause for respondents (Brown & Connery, and Mr. Comerford attorneys; Mr. Comerford, Edward F. Mannino, Katherine Menapace and Jeffery A. Dailey, *1164 of counsel; Michael J. Vassalotti, on the brief).

Before Judges COBURN, WECKER and S.L. REISNER.

The opinion of the court was delivered by

S.L. REISNER, J.A.D.

The Medical Society of New Jersey appeals a trial court order dismissing its complaint against AmeriHealth HMO, Inc. and Independence Blue Cross (collectively designated as "AmeriHealth"). We affirm.

I

The Medical Society, an association of 8,000 New Jersey physicians, filed suit against AmeriHealth on its own behalf and on behalf of its members. The suit alleged that AmeriHealth, a health insurer, had contracted with many of the Society's members to provide health care services to patients covered under AmeriHealth health insurance policies. The Medical Society contended that AmeriHealth had, through a variety of wrongful schemes, either denied, delayed or reduced payment to the contracting physicians for medical care which the doctors had properly provided to AmeriHealth's insureds.

The Society's brief aptly summarizes its complaint as accusing AmeriHealth of the following:

Systematically denying reimbursement to MSNJ members for medically necessary services they have rendered to enrollees in Amerihealth's plans by, inter alia:
1. routinely and unjustifiably refusing to pay for, or reducing payment for, more than one healthcare service per visit or incident — referred to as "bundling";
2. routinely and unjustifiably reducing retroactively the amount of reimbursement remitted to MSNJ members — referred to as "downcoding";
3. routinely and unjustifiably denying increased levels of reimbursement for complicated medical cases which require MSNJ members to expend extra time and resources on the treatment of the patient — referred to as "modifieres";
4. routinely and unjustifiably denying payment for procedures performed during "global periods" for unrelated procedures; and
5. routinely and unjustifiably refusing to pay for treatments by physician specialists by falsely claiming that referrals were not obtained from patients' primary care physicians.
Systematically denying payment to physicians for medically necessary services they have rendered to enrollees in AmeriHealth's plans solely to achieve internal financial targets, without regard for individual patients' medical needs by, inter alia:
1. improperly employing software programs to automatically downcode procedures and/or deny payment to physicians identified as "high utilizers," without any clinical review, oversight or justification;
2. engaging in physician profiling for the purpose of penalizing physicians who provide services in excess of Amerihealth's arbitrary "target"; and
3. improperly applying so-called "guidelines" in a manner that Amerihealth knows is unreasonable for the purpose of denying payment for coverage for medically necessary treatments.
Routinely and unjustifiably failing to make payments to physicians within the time periods prescribed by applicable provisions of New Jersey law, and routinely and unjustifiably failing to pay *1165 interest on past due claims required under applicable provisions of New Jersey law.
Failing to provide adequate staffing to handle MSNJ members' inquiries. In this regard, AmeriHealth has created and maintains an inefficient administrative system designed to frustrate payment to MSNJ members by requiring physicians to make excessive telephone inquiries to obtain proper reimbursement of claims.
Failing to provide sufficient explanation for their payment denials and reductions.
Refusing to provide participating physicians with AmeriHealth's fee schedules for Current Procedure Terminology Codes ("CPT Codes") (the codes recognized by physicians and insurers for reimbursement).
Requiring physicians "to enter into one-sided physician agreements in order for them to provide medical care to patients who receive healthcare through AmeriHealth's managed care plans."
As a result of its improper, unfair and/or deceptive scheme, Amerihealth has deprived MSNJ members of millions of dollars in lawful reimbursement for healthcare services provided to AmeriHealth's plan members which has caused great harm to the practices of MSNJ members.

The Society contended that as a result of these wrongful practices, its physician members had been harmed, and the Society had been frustrated in its organizational purpose of "striving to enhance the delivery of medical care of high quality" to New Jersey residents and had "been required to devote significant resources" in efforts to informally resolve its members' billing disputes with AmeriHealth. The Society also contended that by causing economic injury to the physicians, AmeriHealth was in turn harming the ability of their patients to obtain health care. The Society's complaint sought injunctive and declaratory relief against AmeriHealth on a variety of theories: violation of public policy, the Consumer Fraud Act, violation of the Health Care Information Networks and Technologies (HINT) Act, and tortious interference with prospective economic relations. The complaint did not seek damages.

The trial court initially stayed the case, pending the outcome of motions to certify a class in two Camden County cases filed by physicians against AmeriHealth. Zakheim v. AmeriHealth HMO, Inc., Docket No. CAM-L-6235-00 and Malloy v. AmeriHealth HMO, Inc., Docket No. CAM-L-891-01. The court entered the stay, reasoning that if the Camden County cases were denominated class actions, this case might be appropriately consolidated with them. On May 2, 2003, the Camden cases were certified as class actions. However, on September 22, 2003, the trial court dismissed a virtually identical case against Oxford Health Plans, Inc., holding that the Society's substantive causes of action all failed to state a claim and that the litigation was barred by an arbitration clause.[1] On October 31, 2003, AmeriHealth filed a motion to lift the stay and dismiss the complaint based on the Oxford decision. The Medical Society opposed the motion on the merits, asked the trial court to consolidate their case with the Camden cases, and moved for leave to amend the complaint to include claims for breach of contract and breach of the duty of good faith and fair dealing.

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Bluebook (online)
868 A.2d 1162, 376 N.J. Super. 48, Counsel Stack Legal Research, https://law.counselstack.com/opinion/medical-society-v-amerihealth-hmo-njsuperctappdiv-2005.