Michigan Plastic Surgery Lawyers

Petitioner Was Diagnosed With Type 2 King Adolescent Scoliosis In Surgery Was Performed

On December 13, 2002,  the father of  (Petitioner), filed a request for external review on behalf of the petitioner with the Commissioner of Financial and Insurance Services (Commissioner) under the Patient’s Right to Independent Review Act (PRIRA) MCL 550.1901 et seq. After a review of the material submitted, the Commissioner accepted the request on December 20, 2002.

The issue involved in the adverse determination is contractual. The Commissioner reviews contractual issues pursuant to MCL 550.1911(7). As a result, review by an independent review organization is not required. The Commissioner notified Blue Cross and Blue Shield of Michigan (BCBSM) of this filing and requested the information it used in making its adverse determination. The Office of Financial and Insurance Services received the BCBSM information on January 6, 2003.

Petitioner was diagnosed with type 2 King adolescent scoliosis in  Surgery was performed to correct the condition on  The condition worsened. A second surgery was performed on  at  when Petitioner was old. The hospital and the orthopedic surgeon participated with BCBSM.  performed anesthesia services for this second surgery however, was a non-participating provider anesthesia charge was $4,123.24. BCBSM approved and paid its maximum payment amount of $1,032.20 for this care, which leaves the Petitioner with a balance of $3,091.04.

Has Blue Cross and Blue Shield of Michigan (BCBSM) paid the correct amount for anesthesia services?

According to the petitioner’s father, the petitioner’s first surgery was performed while the petitioner was insured by Blue Care Network (BCN). BCN covered the surgery and anesthesia charges. In  petitioner’s insurance was changed to Blue Cross Blue Shield PPO (BCBSM). Prior to the second surgery, a new primary care physician was selected, and the orthopedic surgeon was determined to be a BCBS participant. Petitioner believes BCBSM should pay the full amount for the anesthesia services. All of the paperwork and procedures were followed. The surgery was performed at the same hospital, by the same physicians who performed the first surgery is the only provider in the area. The Petitioner’s father did not sign a prior agreement.

BCBSM’s Argument

Petitioner has coverage under the BCBSM’s Community Blue Group Benefits Certificate. Rider RAPS (Reimbursement Arrangement for Professional Services) also applies.

Under the Certificate, participating doctors agree to accept BCBSM’s approved amount as payment in full for a covered service. A participating doctor cannot charge the patient the remaining balance even if the BCBSM payment is lower than the amount the doctor normally charges. If the member obtains services from a non-participating doctor, BCBSM will pay the same approved amount it pays to a participating doctor. The non-participating doctor, however, is not bound to accept the BCBSM amount as payment in full. The doctor can bill the patient for the balance.

BCBSM determines the payment level for each service by applying a Resource Based Relative Value Scale (RBRVS). RBRVS reflects the resources required to perform each service. It includes physician time, specialty training, malpractice premiums, practice expenses and overhead. BCBSM regularly reviews the payment level to address the effects of changing technology, training, and medical practice. BCBSM claims the $1,032.20 paid for the , anesthesia care is equal to the maximum amount payable under its system of payment for the procedure performed.

BCBSM claims that participating

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