Sutter v. HORIZON BLUE CROSS

966 A.2d 508, 406 N.J. Super. 86
CourtNew Jersey Superior Court Appellate Division
DecidedMarch 25, 2009
DocketA-3708-06T3
StatusPublished

This text of 966 A.2d 508 (Sutter v. HORIZON BLUE CROSS) 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, 966 A.2d 508, 406 N.J. Super. 86 (N.J. Ct. App. 2009).

Opinion

966 A.2d 508 (2009)
406 N.J. Super. 86

John Ivan SUTTER, M.D., P.A., on behalf of himself and all others similarly situated, Plaintiff-Respondent/Cross-Appellant, and
Mario Criscito, M.D., Barry Prystowsky, M.D., Niranjan V. Rao, M.D., Robert Oberhand, M.D., Alexander Dlugi, M.D., Plaintiffs/Objectors-Appellants/Cross-Respondents,
v.
HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY, Defendant-Respondent.
Union County Medical Society, Mercer County Medical Society, New Jersey Pediatric Society, New Jersey Association of Osteopathic Physicians and Surgeons, American College of Emergency Physicians, Vascular Society of New Jersey, New Jersey Pathology Society, Radiological Society of New Jersey, New Jersey Academy of Ophthalmology, New Jersey State Society of Anesthesiologists, Orthopaedic Surgeons of New Jersey, and New Jersey Chapter of the American College of Cardiology, Appellants/Cross-Respondents.

No. A-3708-06T3

Superior Court of New Jersey, Appellate Division.

Argued January 13, 2009.
Decided March 25, 2009.

*512 Steven I. Kern, Bridgewater, argued the cause for appellants/cross-respondents Union County Medical Society, Mercer County Medical Society, New Jersey Pediatric Society, Mario Criscito, M.D. and Barry Prystowsky, M.D (Kern Augustine Conroy & Schoppmann, attorneys; Mr. Kern, on the joint brief).

Wolf Block Schorr & Solis-Cohen, attorneys for appellants/cross-respondents New Jersey Association of Osteopathic Physicians and Surgeons, American College of Emergency Physicians, Vascular Society of New Jersey, New Jersey Pathology Society, Radiological Society of New Jersey, New Jersey Academy of Ophthalmology, New Jersey State Society of Anesthesiologists, Orthopaedic Surgeons of New Jersey and New Jersey Chapter of the American College of Cardiology (Charles X. Gormally, on the joint brief).

Chasan, Leyner & Lamparello, Secaucus, attorneys for appellants/cross-respondents Niranjan V. Rao, M.D., Robert Oberhand, M.D. and Alexander Dlugi, M.D. (Steven Menaker, on the joint brief).

Eric D. Katz argued the cause for respondent/cross-appellant John Ivan Sutter (Mazie Slater Katz & Freeman, attorneys; Mr. Katz and David Mazie, of counsel; Mr. Katz, Mr. Mazie and Matthew R. Mendelsohn, on the brief).

John M. Murdock of the VA and Washington, DC bar, admitted pro hac vice, argued the cause for respondent Horizon Blue Cross Blue Shield (Epstein Becker & Green, attorneys; Mr. Murdock and Maxine H. Neuhauser, of counsel and on the brief).

*513 Before Judges WEFING, PARKER and LeWINN.

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). Appellants[1] 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.

I

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 *514 Criscito, Barry Prystowsky, Niranjan V. Rao, Robert Oberhand, Alexander Dlugi and Myrna Tagayun[2] opposed the settlement.

The 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.

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