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Q&A
Frequently Asked Questions
- Why did I receive a Settlement Notice?
- Why did I not receive a Settlement Notice?
- What is this case about?
- What is a class action lawsuit?
- Am I covered by this Settlement or what is the definition of the class
- Was Capital found liable for these allegations?
- What liabilities do I have in this class action, and do I need an attorney to represent me?
- Has the Settlement been approved?
- Where can I view a copy of the complete Settlement Agreement?
- What entities are defined as being the "Blue Plan" under the terms of the Settlement?
- How is this Settlement different from the Capital and Keystone settlement in Grider?
- How is this Settlement different from the Highmark settlement?
- How is this Settlement different from the Love Settlement I heard about last fall (mailed November 2007)?
- Is there a fee associated with filing a claim in this class action Settlement?
- What is the Settlement approval procedure?
- What relief does the Settlement provide for the Class?
- What cash compensation is available?
- What types of changes will Capital make going forward?
- What do I need to do to get Prospective Relief?
- When will Prospective Relief be available?
- How much of the Settlement Fund will I receive if my settlement claim is valid?
- How do I submit a Claim Form for cash compensation?
- Can a Physician Group submit a claim form?
- Where do I submit my Claim Form?
- What will happen if there is an error on my Claim Form?
- When will I receive payment from the Settlement Fund?
- Do I need to do anything now?
- Is it possible for me to file my claim electronically?
- What documents are required for someone filing on behalf of a deceased class member?
- Where did you get the information on the physicians, physician groups or physician organizations that were sent Notices?
- Who is Class Counsel?
- How can I object to this Settlement?
- How can I Opt-Out of the Settlement?
- Whom can I contact with questions?
1. Why did I receive a Settlement Notice?
You received a Settlement Notice because you have been identified as a potential member of a Class eligible to participate in a proposed settlement with Capital BlueCross.
2. Why did I not receive a Settlement Notice?
Several companies who specialize in providing contact information for physicians, physician groups or physician organizations provided the mailing addresses. These companies draw on many sources, including the American Medical Association master file which includes both members and non-members of the AMA. The Settlement Notice as well as the Claim Form and Claim Form Instructions are available here, on the Documents screen.
3. What is this case about?
The Complaint alleges, among other things that between May 22, 1999 through March 12, 2008, Capital BlueCross and certain other Blue Plan and Blue Cross and Blue Shield licensed plans, among others, engaged in a conspiracy to improperly deny, delay, and/or reduce payments to physicians.
The Complaint in the Action claims that Capital violated the federal statute called the Racketeer Influenced and Corrupt Organizations Act. Capital denies the factual allegations and legal claims asserted in the Action, and denies any liability or wrongdoing. Nonetheless, in a settlement agreement dated February 1, 2008, Capital has made commitments regarding its business practices. In addition, Capital will fund a Settlement Fund with respect to which individual Physicians who are Class Members will be able to make claims for a settlement payment according to a formula that is set forth in the Settlement Agreement. This settlement is described more fully in a longer notice that has been mailed directly to physicians, physician groups, and physician organizations. If you would like more information about the Action, you can review a copy of the Complaint here.
4. What is a class action lawsuit?
A class action is a type of lawsuit in which one or a few named plaintiffs bring suit on behalf of all the members of a similarly situated group to recover relief for all members of the group. Class actions are used by courts where the claims raise basic issues of law or fact that are common to all members of the class, thereby making it fair to bind all Class Members to the order and the judgment in the case.
5. Am I covered by this Settlement or what is the definition of the class?
The proposed Settlement with Capital will be on behalf of the following Persons:
“Class” means any and all Physicians, Physician Groups and Physician Organizations who provided Covered Services to any Plan Member or services to any individual enrolled in or covered by a Plan offered or administered by any Person named as a defendant in the Complaint or by any other primary licensee of the BCBSA or by any of their respective current or former subsidiaries or Affiliates, in each case from January 1, 1996 through March 12, 2008. The Class shall exclude: (i) all Persons who, in accordance with the terms of this Agreement, execute a timely request for exclusion (Opt-Out) from the Class; and (ii) the Blue Plans, their Affiliates and any of their officers, directors, and employees.
6. Was Capital found liable for these allegations?
Capital was never found liable with respect to any of the allegations, and denies any wrong doing.
7. What liabilities do I have in this class action, and do I need an attorney to represent me?
As a Class Member, you will not have any financial liabilities, nor do you have the responsibility to participate in any legal aspects of the case. Your interests, as well as the interests of all other Class Members, have been represented by Class Counsel, the Plaintiffs’ Attorneys. If you feel that other legal representation is needed, you can retain the services of independent counsel, at your own cost. If you elect to participate in the settlement, however, you will release certain claims - including but not limited to those alleged in this case - that you may have against the defendants. If you want to learn more about the release, the full text can be found at Section 9 of the Settlement Agreement.
8. Has the Settlement been approved?
It has been preliminarily approved by the Court. There will be a final Settlement Hearing - also known as the Fairness Hearing – on June 13, 2008. At that time the Court will make a determination as to whether the Proposed Settlement is fair, reasonable, and adequate and whether it should be finally approved.
9. Where can I view a copy of the complete Settlement Agreement?
The Settlement Agreement as well as additional information about the Settlement can be been seen here.
10. What entities are defined as being the "Blue Plan" under the terms of the Settlement?
Capital BlueCross, Capital Advantage Insurance Company and Keystone Health Plan Central.
11. How is this Settlement different from the Capital and Keystone settlement in Grider?
The Capital and Keystone settlement in Grider is a separate settlement. There is no settlement fund in Grider. To obtain additional information about the settlement in Grider, please call 1-877-559-8630 or go to www.KeystoneCentralPhysicianSettlement.com.
12. How is this Settlement different from the Highmark settlement?
The Highmark Settlement is a different settlement agreement involving different defendants.
13. How is this Settlement different from the Love Settlement I heard about last fall (mailed November 2007)?
The Love v BCBS settlement mailed out to potential class members in November 2007 is a different settlement agreement involving different defendants.
14. Is there a fee associated with filing a claim in this class action Settlement?
No, there are no fees associated with filing a claim.
15. What is the Settlement approval procedure?
The Settlement Hearing will be held on Friday, June 13, at 2:00 PM at the United States Courthouse, Courtroom IV, Tenth Floor, Federal Justice Building, 99 Northeast Fourth Street, Miami, Florida, 33132. However, the order scheduling that hearing also provides that it may be continued by the Court without any additional notice to potential Class Members other than an announcement in open court.
At the Settlement Hearing, the Court will consider several different issues that are listed on Page 5, section IV of the Notice.
The issues the Court will consider include:
- whether the proposed Settlement is fair, reasonable and adequate to the Class Members.
- whether the Court should certify the Class for settlement purposes pursuant to the Federal Rules of Civil Procedure. Among other things, this will require the Court to determine (i) whether questions of law or fact common to the putative Class Members predominate over questions affecting only individual putative Class Members, and (ii) whether a class action is superior to other available methods for fair and efficient adjudication of the controversy. If the Court certifies the Class for settlement purposes, putative Class Members who or which have timely elected to Opt-Out of the Class by following the procedures described below will be excluded from it.
- The Court will consider whether to enter orders that would prevent Class Members and certain other Persons, including the defendants in the Action other than Capital, from asserting certain claims against Capital in the future.
- The Court will consider the applications for a payment of fees by Capital to the Representative Plaintiffs.
- The Court will consider an application by Counsel to the Class for attorneys’ fees and expenses to be paid by Capital.
16. What relief does the Settlement provide for the Class?
The Proposed Settlement offers two forms of relief:
- settlement fund payments to Physicians, who are Class Members and who timely file a Claim Form, from a cash Settlement Fund, and
- Prospective Relief requiring Capital to abide by certain principles and business practices and to disclose certain information about their claims processing policies and procedures on their websites. These changes, as well as others, are more fully described in the Settlement Agreement.
17. What cash compensation is available?
If the Court approves the Settlement, Capital will establish a Fund of three million, four hundred, seventy-nine thousand, nine hundred and eighty-five dollars ($3,479,985) for settlement payments to Class Members. The total payment by Capital is the “Settlement Fund.” The Settlement Fund will be distributed to Class Members who submit valid Claim Forms, or to certain associations to which Class Members direct their share or a portion thereof of the Settlement Fund. To be eligible to receive a portion of the Settlement Fund if the Settlement is approved, you must submit a valid Claim Form to the Settlement Administrator.
18. What types of changes will Capital make going forward?
As a part of the Settlement, Capital has agreed to abide by certain principles and business practices. Please see the Settlement Agreement, page 3, section C of the Notice.
In addition, Capital will disclose certain information about its claims processing policies and procedures on its website. These changes, as well as others, are more fully described in the Settlement Agreement.
Capital has agreed to commitments regarding its business practices. For example, Capital has to:
- continue to fund initiatives to reduce the percentage of resubmitted claims, reduce claims overpayments, communicate requirements on precertifications for services and supplies, communicate on claim status, improve the accuracy of information about the eligibility of Plan Members, and communicate Capital’s claim requirements to Physicians;
- provide relevant Class Members with the ability to view applicable fee schedule amounts for billing codes related to their practice;
- provide notice to Participating Physicians with at least sixty (60) days written notice of material adverse changes to policies and procedures affecting Physicians, as well as an opportunity to terminate contracts with Capital before such changes become effective;
- continue not to require a Participating Physician to participate in all of its products networks;
- make available the definition it uses for medical necessity;
- provide Class Members with information regarding Capital’s process for resolving disputes concerning application of the Blue Plan’s coding and payment rules for fee-for-service claims and Capital’s Medical Necessity internal appeals process and external review process;
- continue to increase Physician access to information regarding the Capital’s automated and other claim payment rules and provide Class Members with information regarding Capital’s policies and procedures regarding claims submissions;
- process and make eligible for payment Physician claims consistent with CPT®, CPT® Conventions and CPT® Guidelines, subject to certain exceptions;
- continue to not automatically reduce the intensity coding of codes for certain covered services;
- continue to meet deadlines for processing and payment of Physician claims;
- meet at least twice a year with the Pennsylvania Medical Society to discuss issues of interest to Capital and Physicians;
- provide to Participating Physicians who receive capitation payments monthly reports with various categories of information;
- randomly assign Plan Members who have not selected a Participating Physician within thirty (30) days of enrollment to a Participating Provider within forty-five (45) calendar days after enrollment; and
- continue its practice of not applying withholds or pharmacy risk pools to capitation arrangements.
19. What do I need to do to get Prospective Relief?
You do not need to do anything to receive Prospective Relief if the Settlement is approved by the Court, as long as you are a Class Member and you do not exclude yourself from the Settlement.
20. When will Prospective Relief be available?
In order to improve its relationship with physicians, physician groups, and physician organizations, some Prospective Relief has already been made available by Capital.
21. How much of the Settlement Fund will I receive if my settlement claim is valid?
The exact amount of the payment that will be made to any particular physician cannot be known until all claims have been filed, but as a part of the Settlement, Capital has agreed to make a settlement payment of $3,479,985 which will be distributed to Physicians who are Class Members and who timely file a Claim Form. If the Settlement is approved by the Court, these Class Members will be entitled to payments from the Settlement Fund in accordance with formulas that are set forth in the Settlement Agreement. Please see page 3, section D of the Notice for details on how the payments are allocated. The Settlement Fund is described in detail in Section 3.1 of the Settlement Agreement.
22. How do I submit a Claim Form for cash compensation?
Class Members who timely submit valid Claim Forms to the Settlement Administrator are eligible to receive payment from the Settlement Fund. To qualify for a settlement payment, you must complete the Claim Form, sign the form, and have it POSTMARKED BY NO LATER THAN JUNE 30, 2008 to:
Capital BlueCross
Settlement Administrator
PO Box 4390
Portland, OR 97208-4390
Please see page 6 of the Notice for additional information on submitting a Claim Form.
23. Can a Physician Group submit a claim form?
Physician Groups and Physician Organizations may submit claim forms on behalf of individual Physicians employed by or otherwise working with them who are Class Members, but not on behalf of, or with respect to Covered Services provided by, any individual Physicians who choose to Opt-Out of the Class and Settlement, or on behalf of individual Physicians who are submitting claim forms on their own behalf involving the same Covered Services.
24. Where do I submit my Claim Form?
Once you have completed the Claim Form, you must mail it to the Settlement Administrator at the address printed on the Claim Form. If you submit your Claim Form by mail, the envelope must be POSTMARKED NO LATER THAN JUNE 30, 2008. If you do not submit your claim form by that date, you will not receive any payment from the Settlement Fund.
25. What will happen if there is an error on my Claim Form?
The Settlement Administrator will notify you by mail if your Claim Form contains an error or insufficient information. You will have an opportunity to correct errors and deficiencies within thirty (30) days of the postmark date of the Settlement Administrator’s notification that your claim was rejected. If you correct the deficiencies within the time permitted and resubmit the Claim Form, the Settlement Administrator will process your claim. You will not be entitled to receive payment if your Claim Form is not resubmitted or if it is still deficient after resubmission. The decision by the Settlement Administrator as to the validity of a Claim Form is final. If you fail to correct a deficient Claim Form, you will be able to receive all other settlement benefits and will continue to be bound by the release and any other Court orders applicable to the class.
26. When will I receive payment from the Settlement Fund?
If the Proposed Settlement is approved and no appeals are filed, Settlement Fund payments will be mailed to the address on your Claim Form. If an appeal is brought concerning the Settlement, payment will be made after the appeal is resolved in favor of the Settlement. If the Court does not approve the Proposed Settlement, no Settlement payments will be made.
27. Do I need to do anything now?
If you want to remain in the class and participate in the Proposed Settlement, you may submit the Claim Form now, by following the instructions on the Claim Form.
You are not required to submit a Claim Form to remain in the class. If you want to remain in the class, but do not want to submit a claim, you do not need to do anything. You will still be a member of the class if the Settlement is approved unless you exclude yourself by following the Opt-Out procedures.
28. Is it possible for me to file my claim electronically?
No, you must complete and sign the claim form, and the envelope returning your claim form must be mailed to the Settlement Administrator with a POSTMARK DATE NO LATER THAN JUNE 30, 2008. If your signed claim form is not postmarked to the settlement administrator by this deadline, you will be deemed to have waived your right to receive any payment.
29. What documents are required for someone filing on behalf of a deceased class member?
Those filing on behalf of a deceased physician must present proof of their legal right to do so with documentation such as a death certificate or letters of administration for an estate. The Tax ID requested in Section C is that of the heir or estate.
30. Where did you get the information on the physicians, physician groups or physician organizations that were sent Notices?
Several companies who specialize in providing contact information for physicians, physician groups or physician organizations provided the mailing addresses. These companies draw on many sources, including the American Medical Association master file which includes both members and non-members of the AMA.
31. Who is Class Counsel?
Class Counsel for this proposed settlement are Whatley, Drake, & Kallas, LLC, Law Offices of Archie Lamb, LLC and Kozyak, Tropin, & Throckmorton. Class Counsel addresses and contacts are listed on page 7 of the Notice or on the website, www.CapitalPhysicianSettlement.com on the Contact Screen.
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Whatley Drake & Kallas, LLC 1540 Broadway, 37th Floor New York, New York 10036 Attention: Edith Kallas |
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Law Offices of Archie Lamb, LLC 2017 2nd Avenue Birmingham, Alabama 35203 Attention: Archie Lamb |
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Kozyak Tropin & Throckmorton 2525 Ponce de Leon Blvd., 9th Floor Miami, Florida 33134 Attention: Harley Tropin |
32. How can I object to this Settlement?
Any potential Class Member, or other interested Person, who or which objects to the proposed Settlement, the Settlement Agreement, the applications for attorneys’ fees, or the other matters to be considered at the Settlement Hearing may appear and present such objections. If you file a timely objection, you will remain in the class and the Judge will consider your objection at the fairness hearing on June 13, 2008. In order to be permitted to object to the proposed Settlement, however, you must, ON OR BEFORE MAY 25, 2008 comply fully with the requirements listed on page 6 of the Notice.
The requirements to object to the proposed Settlement are:
- File with the Court a written statement setting forth your objections to the matters to be considered and the basis for those objections, together with any documentation you want the Court to consider. If you intend to appear at the Settlement Hearing, you must also file a written notice of intention to appear at this same time; and
- Serve copies of all such materials either by hand or overnight delivery upon the following counsel:
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Edith M. Kallas , Joe R. Whatley, Jr., Joseph P. Guglielmo WHATLEY DRAKE & KALLAS LLC 1540 Broadway, 37th Floor New York, NY 10036 |
Archie Lamb, Jr. LAW OFFICES OF ARCHIE LAMB, LLC 2017 Second Avenue North 2nd Floor Birmingham, AL 35203 |
Harley S. Tropin Kozyak Tropin & Throckmorton, P.A. 2525 Ponce de Leon Blvd. 9th Floor Miami, FL 33134 |
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Kathleen Taylor Sooy CROWELL & MORING LLP 1001 Pennsylvania Ave., NW Washington, D.C. 20004 |
If you do not comply with the foregoing procedures and deadlines for filing and serving a written statement setting forth your objections, and a written notice of your intention to appear at the Settlement Hearing, if applicable, you may lose legal rights, including but not limited to: the right to appear and be heard at the Settlement Hearing; the right to contest approval of the proposed Settlement or the application for an award of attorneys’ fees and expenses to Class Counsel; the right to contest approval of the application for the payment of fees to the Representative Plaintiffs and the Representative Plaintiffs in Other Actions; and the right to contest any other orders or judgments of the Court entered in connection with the proposed Settlement.
33. How can I Opt-Out of the Settlement?
If you do not want to be a Class Member and participate in the proposed Settlement, then you must send your written request to Opt-Out of the Class and the Settlement, including your name, business address, telephone number, Federal Tax Identification Number, and signature to the Settlement Administrator post marked no later than May 30, 2008. Please see page 7, section VII of the Notice for additional information on opting out of the proposed Settlement.
Physician Groups or Physician Organizations may exclude themselves, as distinct legal entities, from the Class by submitting a complete and timely request to Opt-Out. Physician Groups or Physician Organizations may not request to Opt-Out individual Physicians, unless the Physician Group or Physician Organization has written authorization to act on behalf of those Physicians, which authorization has been submitted to the Notice Administrator. Individual Physicians seeking to Opt-Out must otherwise submit their own individual, complete and timely request to Opt-Out. Opt-Out requests must be submitted to:
Capital BlueCross
Settlement Administrator
PO Box 3775
Portland, OR 97208-3775
To be considered timely and to effectively opt-out of the Class and the Settlement, your complete and signed opt-out request must be postmarked by no later than May 30, 2008. If it is not postmarked by that date, your right to opt-out will be deemed waived and you will be bound by all Orders and Judgments entered in connection with the Settlement.
If you choose to Opt-Out of the Settlement and the Class, you will not be entitled to receive the benefits of the proposed Settlement with the Blue Plans, including any payment from the Settlement Fund and any benefit from the business practice commitments specified in the Settlement Agreement. Your claims against the Blue Plans will not be released, and you will be free to pursue any claims you believe you have by filing a separate action or request for arbitration if you are subject to an arbitration agreement.
Any putative Class Member who or which timely submits a request to Opt-Out of the Class and the Settlement will have until the Settlement Hearing to deliver to the Settlement Administrator a written revocation of the request to Opt-Out and shall thereby become a Class Member.
34. Whom can I contact with questions?
PLEASE DO NOT CALL CAPITAL BLUECROSS, CAPITAL ADVANTAGE INSURANCE COMPANY OR KEYSTONE HEALTH PLAN CENTRAL, INC. THEIR PROVIDER RELATIONS REPRESENTATIVE, THE COURT, OR THE CLERK’S OFFICE
Class Counsel Websites, addresses, and contacts are listed on page 7 of the Notice or on the Contact Screen, or you may write to the Settlement Administrator at:
Capital BlueCross
Settlement Administrator
PO Box 4390
Portland, OR 97208-4390
On the Internet, at any of these sites:
By Mail to Class Counsel at:
Whatley Drake & Kallas, LLC
1540 Broadway, 37th Floor
New York, New York 10036
Attention: Edith Kallas
Law Offices of Archie Lamb, LLC
2017 2nd Avenue
Birmingham, Alabama 35203
Attention: Archie Lamb
Kozyak Tropin & Throckmorton
2525 Ponce de Leon Blvd., 9th Floor
Miami, Florida 33134
Attention: Harley Tropin