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Medical Ass'n of Ga. v. Blue Cross & Blue Shield of Ga. Inc.

Doctors were entitled to health insurance provider's fee schedule and methodology for determining reimbursement amounts for doctors' medical services.

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Doctors Joe Stubbs, Neal Kahn, Janice Johnston and Anthony Costrini entered into contracts with health insurance provider Blue Cross & Blue Shield of Georgia, Inc. The doctors contracted to provide medical services to Blue Cross members in exchange for reimbursement by Blue Cross of the usual, customary and reasonable fees for the services. The contracts provide that Blue Cross has authority to determine usual, customary and reasonable fees, and that when the doctors’ charges exceed the usual, customary and reasonable allowance the doctors shall abide by Blue Cross’ rules and regulations. The first paragraph of those rules and regulations confirms that a doctor’s participation in the Blue Cross plan indicates an agreement to abide by such rules and regulations.

According to the rules and regulations, the usual, customary and reasonable fee program may be changed or supplemented when deemed advisable by Blue Cross in order to reflect changing conditions. The rules further provide: “Reimbursement programs are subject to change, both generally, as to methodology, and specifically for certain customers, geographic areas, services or supplies. Participating Physicians will be notified of changes in reimbursement programs at least 30 days prior to the effective date of any change.”

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