BCBS awarded payment in lawsuit
From staff reportsPARKERSBURG - More than $180,000 for overpayments made to a Clay County physician was awarded to Mountain State Blue Cross Blue Shield by Wood County Circuit Court.
According to the summary judgment granted on Jan. 5, Dr. Sharooz S. Jamie submitted multiple medical claims to the insurer without performing the services billed.
In the order signed by Wood County Circuit Court Judge J.D. Beane, the insurer was awarded $182,047.86 in compensatory damages and $94,060.07 in prejudgment interest for a total of $276,107.93
Mountain State personnel identified a potential problem with claims for blood test panels submitted by Dr. Jamie in August 2003. Even though Dr. Jamie, who became a network provider in 1991, practiced in a rural area with a stable population, the number of blood test panels he claimed to be performing exceeded by hundreds the number performed by his peer providers, the order states.
Further review revealed multiple blood test panels were being billed by Dr. Jamie for the same patients on the same days, in addition to claims being submitted for unperformed blood draws and allergy injections, it states.
Mountain State provided Dr. Jamie several opportunities to repay the overpayments. He refused, and instead opted to cancel his participation in the Mountain State provider network, ultimately forcing Blue Cross Blue Shield to file a lawsuit, officials said.
"Mountain State is not in the habit of suing its providers and, in fact, is very reluctant to bring a suit," said J. Fred Earley II, general counsel for Mountain State Blue Cross Blue Shield. "However, Mountain State has an obligation to its members to seek repayment of verified overpayments, and it will use the courts if necessary. In the case of Dr. Jamie, it was necessary."
Beane issued a summary judgment order in Mountain State's favor on its breach of contract claim, signifying Mountain State was entitled to a judgment without trial.
In Beane's opinion there was no way the physician could dispute the company's claims.
"With regard to the incorrect, inaccurate and wrongful billing practices alleged by (Mountain State Blue Cross Blue Shield), Dr. Jamie does not, and cannot, dispute that he overbilled the plaintiff by submitting claims for services and procedures he did not perform," Beane wrote.
"It is unfortunate that we had to resort to litigation to recover overpayments that Dr. Jamie wrongfully obtained, but we are pleased with the result," Earley said. "Doctors who are paid for wrongful claims hurt all of our members. While we would prefer not to litigate, this case has proven that we can succeed if forced to go to court."
Mountain State Blue Cross Blue Shield is an independent licensee of the Blue Cross and Blue Shield Association. Mountain State provides or administers coverage to more than 500,000 West Virginians. Additionally, it provides coverage to members of the Federal Employee Health Benefits Program and processes Medicare Advantage claims as a subcontractor. The company has about 1,000 employees in Parkersburg, Charleston, Wheeling and Weirton.
