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Medical Society of New Jersey v. Amerihealth HMO

March 16, 2005

MEDICAL SOCIETY OF NEW JERSEY, PLAINTIFF-APPELLANT,
v.
AMERIHEALTH HMO, INC. AND INDEPENDENCE BLUE CROSS, DEFENDANTS-RESPONDENTS.



On appeal from the Superior Court of New Jersey, Chancery Division, Mercer County, C-66-02.

Before Judges Coburn, Wecker and S.L. Reisner.

The opinion of the court was delivered by: S.L. Reisner, J.A.D.

NOT FOR PUBLICATION WITHOUT THE APPROVAL OF THE APPELLATE DIVISION

Argued January 4, 2005

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 ...


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