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Court Grants Doctors Class-Action Status in Reimbursement Suit

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Case ID: 4961 | Drugs / Medical | 12/27/2006

Thousands of Pennsylvania doctors may be eligible to join a lawsuit over a Blue Cross health plan's reimbursement rates after a federal judge granted the plaintiffs class-action status.

The suit charges that Keystone Health Plan Central systematically lowered its reimbursement rates to doctors by bundling or changing procedure codes; failing to pay legitimate claims on time; undercounting the number of patients assigned to doctors in the managed-care plan; and other practices.

The plaintiffs accuse the health maintenance organization of fraud and racketeering, paralleling a strategy used in suits nationwide over managed-care rates.

The lawsuit case involves medical claims dating from January 1996 through November 2001, when the lawsuit was filed on behalf of a Kutztown doctor and her practice group.

Keystone Health Plan Central, which serves central Pennsylvania and the Lehigh Valley, was co-owned at the time by Highmark Inc., a Blue Shield affiliate, and Capital Blue Cross. It had more than 6,400 participating physicians in 2001, according to court documents.

The lawsuit seeks to represent physicians who were overcharged or not reimbursed by Keystone Health Plan Central.


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