The pathology groups suing Health Options in Florida were able to do so because they are not participating providers, says Steven Weinstein of the Miami law firm K&L Gates.
“The vast majority of pathologists are participating—they have a contract with Blue Cross Blue Shield and its affiliates. The reason Palmetto and the others did not have a contract is because Blue Cross Blue Shield and its HMO Health Options were unwilling to pay anything for PC-CP. So these groups said, ‘We are not contracting with you unless you give a reasonable rate.’ A lot of other pathologists, because they were pressured by their facilities or because of business reasons, agreed, but these groups said no.”
Each individual specialty has its own difficulties with HMOs, says Michael Abels, MD, of Palmetto Pathology Services, whether they concern reimbursement rates or covered services. “But pathology is unique inasmuch as some HMOs are trying to divide our practices into ‘hands-on’ anatomic pathology and our responsibility to our patients by our involvement in clinical pathology.”
One of Health Options’ strategies was to develop an all-business line contract and offer it to pathologists, he says. “They would pay pathologists a premium for anatomic pathology services, in exchange for a recognition that they would not get paid for clinical pathology. Some of the pathologists in the state accepted that offer, but some of us basically said that is a denigration and denial of half of my medical expertise and training and my daily responsibilities, and refused to accept it.”
Nevertheless, the ruling potentially affects all pathologists in the state, Weinstein says.
“In addition to the money for unpaid claims for PC-CP, judge Wilson made a declaratory judgment” on payment for PC-CP services. “He issued a judicial decree, with the court determining that as a matter of law the pathologist is entitled to payment from the HMO for professional pathology services rendered, and the HMO has to pay the pathologist directly for those services.”
If that decree is upheld by the Third District Court of Appeals, then it would certainly be a highly persuasive if not binding precedent on all the courts in the district, he says. “It will significantly affect contract negotiations as well.”
Anne Paxton is a writer in Seattle.