Legal News Archive
Please select the links below for complete Legal News articles and documents from previous years. View Current Legal News
12.13.07 MAG Takes On BCBS In “Any Willing Provider” Dispute
MAG’s Office of the General Counsel has filed an amicus curiae brief in opposition to providing HMOs an exemption from Georgia’s “Any Willing Provider” law. Northeast Georgia Cancer Care filed suit against Blue Cross Blue Shield of Georgia alleging the insurance giant’s refusal to allow its medical oncologists to participate in BCBS’s HMO network violates Georgia’s “Any Willing Provider” law.
BCBS has requested the Court dismiss the physicians’ suit, in part, on the theory Georgia’s “Any Willing Provider” law does not apply to HMOs. In its brief, MAG argued exempting HMOs from Georgia’s “Any Willing Provider” law is contrary to the public policy of the State of Georgia and the intent of the legislature to grant patients the right to continuity of care and to choose their own physicians.
Download the Full Brief
12.12.07 Tiered and Narrow Physician Networks: How to Challenge your Profile or Placement
MAG's offices of the General Counsel and Third Party Payer Advocacy have teamed up with the AMA to disseminate a flyer giving tips on ways to challenge and improve your profile or placement.
Download Tiered Network Flyer
12.05.07 MAG Legal Victory Protects Physicians:
State’s High Court Agrees With MAG, Upholds the Constitutionality of Georgia’s Statute Of Repose
Fending off yet another attempt by plaintiffs’ lawyers to reduce physicians’ legal protections, MAG persuaded the Supreme Court of Georgia, in a unanimous opinion, to reject a constitutional challenge to Georgia’s statute of repose.
Under Georgia’s statute of repose, a lawsuit for medical malpractice may not be brought more than five years after the date on which the negligent act occurred. In Nichols v. Gross, et al., the plaintiff filed a medical malpractice lawsuit almost seven years after the date of the alleged negligent act. Finding the suit was barred by the statute of repose, the trial court granted the physician summary judgment. On appeal, the plaintiff argued Georgia’s statute of repose violates the equal protection provisions of the United States and Georgia constitutions because it treated medical malpractice claims differently than other claims for professional malpractice.
Citing precedent and noting the differences between the practice of medicine and other professions, the Court determined the purpose of the statute of repose was rational and therefore the statute was constitutional.
12.03.07 BCBS Settlement Party Information for Georgia on AMA's Web site
The AMA has gathered information on the Blue Cross Blue Shield Parties' Settlement and posted it on their Web site at www.ama-assn.org/go/settlements. In an attempt to simplify the complex BCBS parties settlement, the AMA has created an interactive map through which physicians and their staff can view state-specific information, including which health insurers have or have not settled under this settlement.
View the Map and Information for Georgia
View Party-Specific Provisions
11.07.07 MAG Requesting Physician Reports on Health Plan Tiering:
Aetna Aexcel Designation; United Health Premium and Cigna Care
During recent months, many physicians have received letters from Aetna and United Health Care informing them whether they passed certain quality of care and efficiency measures for special designation under new or revised “Tiering” programs. These reports are often placed on the health plans’ Web site for viewing by patients and, reportedly, for health plans to move patients to higher quality and more efficient physicians.
MAG has received several reports from physicians about inaccuracies in these reports, including the addition of hospital charges in the physician profile. MAG is concerned about the misrepresentation of physician’s profiles based on inaccurate data and would like to hear from you. If you have noticed improper or incorrect data included, please send MAG copies of your designation report and background data. The information can be e-mailed, faxed or sent to:
Donald Palmisano, General Counsel, dpalmisano@mag.org
Cam Grayson, Director, Third Party Payer Advocacy, cgrayson@mag.org
Medical Association of Georgia
1849 The Exchange
Suite 200
Atlanta, GA 30339
Fax: 678.303.3732
If you have any questions, please contact Donald or Cam at 1.800.282.0224 or 678.303.9290.
10.29.07 Supreme Court Rules in Favor of Physicians; MAG Filed Amicus Brief in Case
Protecting the rights of physicians, MAG filed an Amicus Brief before the Georgia Supreme Court in a case in which the Georgia Court of Appeals extended the new injury doctrine. The Georgia Supreme Court reversed the Georgia Court of Appeals and found in favor of the physicians stating the statute of limitations begins at the time of the original misdiagnosis. The court found that a continued misdiagnosis causing more severe symptoms cannot be considered a new negligent act.
Read Georgia Supreme Court's Opinion
09.14.07 STARK Legal Alert from Powell Goldstein LLP and MAG's Office of the General Counsel
On August 27, 2007, the Centers for Medicare and Medicaid Services (CMS) released the third phase of rulemaking to amend the regulations implementing the Ethics in Patient Referrals Act, commonly known as “Stark.” This Phase III Final Rule (Phase III) was published on September 5, 2007 and will become effective 90 days later, on December 5, 2007. In publishing Phase III, CMS both responds to public comments on Phase II and addresses the entire regulatory scheme.
Although CMS states that Phase III “addresses many of the industry’s primary concerns,” Phase III is not the last we will experience in the world of Stark change. CMS states in Phase III that further rulemaking will be undertaken in several areas discussed in this rulemaking. Recent agency proposals include significant provisions affecting physician ownership of hospitals and various terms of Stark compensation exceptions. CMS has yet to address (as promised in Stark II) the applicability of Stark to Medicaid. Other pending proposals address reassignment of Medicare payments and the structuring of independent diagnostic laboratory testing (“IDTF”) facilities, which likely will impact Stark. While further change is likely, this article will focus on the most important changes wrought through Phase III.
Read Legal Alert on Phase III
09.17.07 Physician Education on Advance Directives
As you make use of the new Advance Directives, it may be helpful for you to read some of the most current materials on the topic in order to properly advise your patient. If you are looking for some general overview education programs and some more specific to Georgia law, we recommend the following:
- The AMA has produced several excellent papers and programs on Decisions About End-Of-Life care. AMA policy and JAMA articles on End-of-Life care can be found at the AMA Ethics Resource Center and under AMA's Virtual Mentor program on End-of-Life Care .
- State-specific advance directives can be downloaded on the National Hospice and Palliative Care Organization site. The NHPCO provides examples of advance directives - living wills and power of health care attorney appointment forms - for each state on the Web.
- In Georgia, Georgia Health Decisions, located at Georgia State Univeristy has produced patient and clinician materials which can be found at www.critical-conditions.org or by calling toll free at 877.633.2433. That office is presently updating their materials based on recent Georgia legislation and MAG is working with them in obtaining possible CME credits.
09.05.07 Joint Commission Releases Revision Pertaining to Hospital Safety Concerns
Physicians and medical staff members who have concerns about the safety and quality of care at their hospital may report those concerns with the understanding that retaliatory disciplinary action is prohibited, according to explicit new rules announced by The Joint Commission. The accreditation participation requirement previously referred generally to hospital staff, although it has always been intended that physicians and medical staff be included as part of 'Good Faith Participation' in the accreditation policy.
The revised requirement, which will become effective January 1, 2008, means that accredited hospitals must educate staff and medical staff that any employee or any physician who has concerns about the safety or quality of care provided in the hospital may report these concerns to The Joint Commission. Hospitals also are expected to inform staff and medical staff that no disciplinary action will be taken if concerns are shared with The Joint Commission, and hospitals should demonstrate this commitment by refraining from taking action against employees or physicians who report their concerns to The Joint Commission.
Read The Joint Commission News Release
08.22.07MAG Victorious in Court Ruling Against UnitedHealthcare
The Superior Court of Fulton County determined that the physician fee schedules and provider contracts with UnitedHealthcare, as part of the State Health Benefits Plan (SHBP), were subject to the Open Records Act. This ruling was a result of MAG’s Office of the General Counsel filing an Open Records request with United and the Department of Community Health (DCH) in June 2006.
The State holds a contract with United for claims administration, care management and maintenance of a state and national provider network for the SHBP. United’s role as a SHBP third party administrator allows them to act as an agent and negotiate contracts for the state. United and DCH were ordered by the Court to turn over the physician fee schedules and provider contracts to MAG. United has filed a Notice of Appeal. As a result, MAG will not be able to obtain these documents until the appeal is heard.
Read the Superior Court Motion
08.06.07 Humana Distributes Settlement Payments to Georgia Physicians
Your MAG membership continues to work hard for you! As part of the MDL RICO settlements, Georgia physicians will begin receiving disbursements in the Humana and HealthNet settlements, because payments were mailed on August 6. The base share for the Humana settlement is $78.91 and the retired share is $84.21. These cash payments have been expedited by the strong involvement of MAG and several other state medical societies. Please call the Office of the General Counsel at 678.303.9281 with any questions.
07.27.07 BCBS Claims Now Being Accepted; Deadline Oct. 19
In May, Judge Moreno approved the Blue Cross Blue Shield settlement, in the Multidistrict Litigation RICO case. The national class action lawsuit was settled in late April with over 90 percent of all Blue Cross and Blue Shield (BCBS) Plans in the country and the Blue Cross and Blue Shield (BCBS) Association. The deadline for submitted claims is October 19, 2007. For questions about this or any of the MDL RICO settlements, please contact MAG’s Office of the General Counsel at 678.303.9281 or e-mail Donald Palmisano.
MAG was the first state medical society to bring a class action lawsuit against the insurance industry alleging improper payment practices. MAG’s lawsuit and subsequent lawsuits brought by other state medical societies were combined in a massive multi-state litigation alleging a conspiracy to defraud physicians out of payments by inappropriately bundling and downcoding claims.
The practice changes the Blues plans have agreed to include commitments to do the following:
- Implement a definition of medical necessity that ensures that patients are entitled to receive medically necessary care as determined by a physician exercising clinically prudent judgment in accordance with generally accepted standards of medical practice;
- Use clinical guidelines that are based on credible scientific evidence published in peer-reviewed medical literature (taking into account Physician Specialty Society recommendations, the views of physicians practicing in the relevant clinical areas, and other relevant factors) when making medical necessity determinations;
- Provide physicians with access to an independent medical necessity external review process;
- Establish an independent external review board for resolving disputes with physicians concerning many common billing disputes;
- Pay for the cost of recommended vaccines and injectibles and for the administration of such vaccines and injectibles;
- Not automatically reduce the intensity coding of evaluation and management codes billed for covered services;
- Ensure the payment of valid clean claims within 15 days for electronically-submitted claims and 30 days for paper claims;
- Provide fee schedules to physicians;
- Establish a compliance dispute mechanism to address disputes regarding the Blues’ compliance with the agreement;
- Establish and/or maintain physician advisory committees; and
- Provide 90 days’ notice of changes in practices and policies and annual changes to fee schedules.
07.18.07 MAG Reminds Physicians of Proper Record Disposal Requirements
The Governor’s Office of Consumer Affairs (OCA) has been notified of several incidences of businesses discarding medical records containing personal patient information without first obscuring or obliterating the confidential information contained therein. OCA wishes to remind those in the medical industry about Georgia’s Business Administration Act (BAA), which regulates the proper disposal of customer records that contain sensitive information about a customer’s medical condition or certain financial data relating to a customer’s account or transaction with a business. According to the BAA, once such records are no longer needed, a business must do one of the following before discarding them:
- Shred the record;
- Erase the personal information contained in the record;
- Modify the record so that the personal information is unreadable; or
- Take actions that will ensure that no unauthorized person will have access to the personal information contained in the records.
Read Governor's OCA Press Release
07.01.07 MAG's Legislative Priority on Advanced Directives Takes Effect
In 2006, MAG identified updating Georgia’s law on advanced directives as a top legislative priority. About one-fourth of Medicare costs are for the last year of life, unchanged from 20 years ago. These high costs reflect care for multiple severe illnesses typically present near death. Doing a better job of managing end-of-life care is a crucial component of real health care reform. That is why MAG spearheaded the effort, which successfully culminated in passage of a modern advanced directives statute.
Following two years of preparation, Georgia’s new law regarding advanced directives took effect July 1, 2007. Under the new law, there is one statutory form that can be utilized to execute a living will, durable power of attorney for health care and/or a guardianship. A patient may choose to execute just one or all three of the aforementioned provisions. The form contains simple, easy-to-understand instructions.
Download New Advanced Directive Form
06.06.07 MAG files Amicus Curiae Brief in case concerning Georgia’s Statute of Repose
MAG’s Office of the General Counsel filed an Amicus Curiae Brief with the Georgia Supreme Court in support of the Court’s well-established position that the Statute of Repose in medical malpractice claims is constitutional and does not violate the principles of equal protection.
View Amicus Curiae Brief
06.01.07 CIGNA Accepting Previously Denied CAD Mammography Claims
Due to the efforts of MAG and other medical societies involved with the Physicians Advocacy Institute (PAI), physicians may resubmit their previously denied CAD mammography claims to CIGNA. This opportunity to resubmit claims is another victory resulting from the settlements in the national MDL class action lawsuits against the nation’s for-profit health plans. MAG and PAI used the formal compliance dispute resolution process that was part of the CIGNA Settlement Agreement to force CIGNA to pay these claims. Eligible claims must:
- Involve CPT® Codes 76082 or 76082 as add-on codes with 76090, 76091, or 76092 and
- Have been submitted between Jan. 1, 2004, when the CAD Mammography add-on codes became effective, and Oct. 10, 2004, when CIGNA began paying the claims.
Resubmitting claims is simple. Complete the spreadsheet that is available on below. It is also on www.hmosettlements.com or www.CIGNA.com. Completed spreadsheets and questions should be E-mailed to CADMammoRebsubmit@CIGNA.com. Physicians without access to E-mail can send their completed spreadsheets to:
CIGNA R&R Department P&C
P.O. Box 9018
Sherman, TX 75091-9018
Claims can be resubmitted beginning June 1, 2007 through Dec. 1, 2007.
For questions or if you believe that Aetna, CIGNA, HealthNet, Humana or Anthem/Wellpoint are violating the terms of their settlement agreements, please contact MAG’s Office of the General Counsel at 678.303.9281 or dpalmisano@mag.org.
Download CIGNA Spreadsheet
05.11.07 On behalf of physicians, the Medical Association of Georgia files Amicus Curiae Brief to the Georgia Supreme Court on the Court of Appeals’ decision to extend the “new injury” doctrine.
MAG’s Office of the General Counsel filed an Amicus Curiae Brief with the Georgia Supreme Court requesting that they reverse the Georgia Court of Appeals decision holding that if a plaintiff in a misdiagnosis case presents with additional or significantly increased symptoms of the same misdiagnosed disease, the medical malpractice statute of limitation and statute of repose do not bar the plaintiff’s claims.
MAG, along with the Georgia Hospital Association, are justifiably concerned with issues related to a physician’s liability and believe the Court of Appeals’ decision impermissibly extends the “new injury” doctrine beyond actual new injuries to those injuries, which are merely symptoms of the same underlying disease.
View Amicus Curiae Brief
05.02.07 Medical Association of Georgia files Amicus Curiae Brief
MAG’s Office of the General Counsel filed an Amicus Curiae Brief with the Georgia Supreme Court in support of the Old Capitol Inn Nursing Home against the Georgia Department of Community Health. The case centers on DCH’s “policies and procedures” manuals, which set forth terms and conditions of reimbursement for health care providers who contract with Medicaid. The Court of Appeals has ruled that policies and procedures manuals are to be interpreted in the same manner as regulations, rather than as contracts. The Court of Appeals ruling is a radical departure from judicial precedent that applies contract principles to reimbursement disputes between health care providers and DCH.
MAG, along with the Georgia Hospital Association, Georgia Health Care Association, Georgia Pharmacy Association, Georgia Dental Association and Georgia Psychological Association, believes this decision treats providers who voluntarily participate in the Medicaid program unfairly as it gives a heightened standard of deference to DCH in interpreting its own rules and regulations in matters of reimbursement.
View Amicus Curiae Brief
02.01.07 Timely Completion of Certificates of Death
The Medical Association of Georgia would like to take the opportunity to remind our members of the importance of timely completing certificates of death. Except in limited circumstances, only a physician authorized to practice medicine is permitted to complete death certificates.
View PDF
01.11.07 Medical Staff Bylaws
The "Medical Staff Bylaws-'Basics in Georgia Law'" was produced by the Office of the General Counsel. This document is presented in a question/answer format in an attempt to answer the most commonly asked questions regarding medical staff bylaws. It is an educational and informational tool which is simply illustrative of the issues facing medical staffs. Please note issues such as peer review are not discussed in detail. This document does not constitute legal advice and you are encouraged to consult with an independent medical staff attorney when confronted with issues regarding medical staff bylaws.
In the very near future, the MAG Model Medical Staff Bylaws will be complete. Libby Snelson, the attorney preparing the document, is completing the second draft of the bylaws. When this document is complete, you will be notified.
View PDF
08.01.06 MAG files Amicus Curiae brief
The Medical Association of Georgia has filed an Amicus Curiae brief in the Georgia Supreme Court case of Satilla Health Services dba Satilla Regional Medical Center v. Willie Bell, M.D. and Joel Ferree, M.D.
Read more
05.26.06 Modifier –25 Dispute with Aetna Resolved
As part of MAG’s landmark settlement with Aetna in the MDL RICO litigation, Aetna was required to pay physicians for both a procedure code and an evaluation and management code, appended with a modifier –25 when billed together.
Read more
05.26.06 Final order in the compliance dispute
View PDF
05.26.06 Codes to be reprocessed when billed with an E&M code appended with a -25 modifier
View PDF
04.06 BCBSGA RICO Contract Addendum Received
View PDF
04.06 Aetna Agrees to E&M Payments with Modifiers
View PDF
04.06 What to Do When Submitting Your Aetna Claims
Submit impacted claims with a cover letter that includes a subject line that reads "Rework Request for E&M Codes" or call the Aetna Provider Service Center to verbally request rework of the impacted claims.
Read more
04.17.06 MAG Instrumental in Settling Dispute Over “Add-On Codes”
MAG and several other state medical societies have reached an agreement with Aetna in regards to the resubmission of claims, after their failure to pay for certain add-on codes as required by the lawsuit settlement in May 2003.
Read more
04.17.06 Aetna Add On Code Claims Payment
Submit claims
*Some of the documents listed here are available in PDF format and can be viewed using Adobe Acrobat Reader®. This free software can be downloaded from the Adobe® site, http://www.adobe.com.