Sutter v. Horizon Blue Cross Blue Shield

966 A.2d 508, 406 N.J. Super. 86, 2009 N.J. Super. LEXIS 60
CourtNew Jersey Superior Court Appellate Division
DecidedMarch 25, 2009
StatusPublished
Cited by11 cases

This text of 966 A.2d 508 (Sutter v. Horizon Blue Cross Blue Shield) 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
Sutter v. Horizon Blue Cross Blue Shield, 966 A.2d 508, 406 N.J. Super. 86, 2009 N.J. Super. LEXIS 60 (N.J. Ct. App. 2009).

Opinion

The opinion of the court was delivered by

PARKER, J.A.D.

In this appeal, we address the settlement of a class action that was instituted by New Jersey physicians against Horizon Blue Cross Blue Shield of New Jersey (Horizon). Appellants1 are members of the class who objected to the settlement and the medical societies who sought to intervene, arguing that the settlement is illusory because it requires nothing more of Horizon than is required under the law and under its contracts. Appellants further argue that the attorneys’ fees awarded to class counsel were grossly excessive. The medical societies argue that the trial court erred in denying their motion to intervene.

Plaintiff John Ivan Sutter, M.D., is the representative physician of the class of physicians. Plaintiffs argue in their cross-appeal that the appeal should be dismissed because all of the objectors are hostile to the interests of the class and some of the medical society appellants never moved to intervene in the trial court.

After considering the parties’ arguments and the voluminous record on appeal in light of the applicable law, we are remanding the matter for a testimonial hearing and more adequate fact finding by the trial court as to the reasonableness of the settlement and for reconsideration of the attorneys’ fees awarded.

[95]*95I

The facts relevant to this appeal are as follows. The complaint alleged that physicians who rendered medical services to patient-members of Horizon’s health care plans were harmed by Horizon’s “repeated improper, unfair and deceptive acts and practices ... which [were] designed to delay, deny, impede and reduce compensation to [plaintiffs].” Plaintiffs first claimed that Horizon failed to make prompt payments of claims and that Horizon engaged in “bundling,” that is, it refused to provide compensation for a particular medical procedure by improperly including it in another procedure performed on the same date of service. Plaintiffs further alleged that Horizon engaged in “downcoding” of claims, which meant that it unilaterally and retroactively reduced the amount of compensation paid for medical services by changing the procedure codes to a procedure of lesser complexity. Finally, plaintiffs alleged that Horizon refused to recognize “modifiers” in cases in which additional medical services were required to treat more complex conditions or separate and unrelated conditions.

In certifying the class, the trial court permitted two sub-classes for all New Jersey physicians: a “prompt payment” class and a “capitation” class. A separate class of pediatricians was certified for claims of “downcoding,” “bundling” and “refusal to recognize modifiers.”

In June 2005, the trial court severed the claims of the prompt payment sub-class for trial. On the eve of trial, the parties agreed to a settlement. On October 24, 2006, the court signed a preliminary order of approval. Plaintiffs sent notice of the proposed settlement to the class members. Six members of the class, plaintiffs/objectors-appellants/cross-respondents Mario Criscito, Barry Prystowsky, Niranjan V. Rao, Robert Oberhand, Alexander Dlugi and Myrna Tagayun2 opposed the settlement.

[96]*96The medical societies of Union and Mercer Counties and the New Jersey Pediatric Society moved to intervene to object to the settlement. The intervention motion was denied in an order entered on December 15, 2006.

On December 20, 2006, the court conducted a fairness hearing pursuant to Rule 4:32-2(e) on the prompt payment settlement proposal and allowed all of the objectors to argue, even those who were not accorded intervenor status. No testimony was taken, however. On February 2, 2007, the court rendered a written decision and entered an order approving the settlement and class counsel’s fees and costs in the amount of $6.5 million.

Appellants moved for a stay of the fee award, which class counsel had opposed. The stay was apparently denied, but no order memorializing that ruling has been provided to us.

II

Appellants are critical of the following sections in the proposed settlement. Section 7.1 concerns “Disclosure of Significant Edits.” An “edit” is an “adjustment” of the CPT codes or HCPCS Level II Codes, which were developed by the American Medical Association and used by all doctors to describe certain medical and surgical procedures. A “significant edit” was one that Horizon believed, based on its experience, would cause the denial of or reduction in payment for a particular CPT code or HCPCS Level II code. Under the settlement, once a year on its website, Horizon agreed to list every CPT and HCPCS Level II code combination that resulted in a significant reduction or a denial of payment, if such code edits occurred more than 250 times per year.

Section 7.2 obligates Horizon to give ninety days written notice if it intends to make material adverse changes to the terms of the contract, and allows a physician to terminate his or her contract upon objection to the proposed change.

[97]*97Section 7.4 establishes a “Capitation Liaison,” who would be responsible for resolving capitation inquiries and capitation payment issues. “Capitation” is the payment of a per-member-per-month amount by Horizon to the physician, “by which Horizon transfers to the provider the financial risk for those Covered Services as set forth in the contract between Horizon and the provider.”

Section 7.5 permits participating physicians to close their practices to all new Horizon patients.

Section 7.6 obligates Horizon to provide complete fee schedules “typically” used in the participating physician’s group, pursuant to their agreement with Horizon, upon the physician’s request. Twice a year, the physicians can request the fee-for-service amounts of up to fifty other CPT codes or HCPCS Level II codes that the physician actually billed or anticipates billing.

In Section 7.8, Horizon agrees not to initiate overpayment recovery procedures more than eighteen months after payment is received by a physician.

Section 7.9 precludes Horizon from revoking a “medical necessity” determination once it has been pre-certified.

Section 7.10 precludes Horizon from using “Most Favored Nations” clauses, that is, provisions requiring that Horizon receive the most advantageous contract terms and conditions, including reimbursement rates, that a participating physician agrees to with any other third party.

Section 7.11(b) precludes Horizon from imposing a “Pharmacy Risk Pool,” whereby amounts payable to participating physicians could be reduced if plan members used certain pharmacies.

In Section 7.15, the parties estimated the approximate aggregate value of the settlement at $39 million allocated as follows: $30.61 million for disclosure of significant edits, $3.49 million for capitation reporting and dedicated liaison, and $4.13 million for limitations on over-payment recovery for insured lines of business. This provision was based upon a report dated October 9, 2006 by [98]*98Teresa M. Waters, Ph.D., plaintiffs’ economic expert. Waters submitted six reports over the course of the litigation. The first report claimed damages in the amount of $490,502,695. In the October 9, 2006 report, however, she reduced that figure to $39 million, stating:

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Sutter v. HORIZON BLUE CROSS
966 A.2d 508 (New Jersey Superior Court App Division, 2009)

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Bluebook (online)
966 A.2d 508, 406 N.J. Super. 86, 2009 N.J. Super. LEXIS 60, Counsel Stack Legal Research, https://law.counselstack.com/opinion/sutter-v-horizon-blue-cross-blue-shield-njsuperctappdiv-2009.