Mountain State Blue Cross Blue Shield Awarded Payment in Lawsuit against Former Network Provider

January 12, 2009

PARKERSBURG, WV – The Wood County Circuit Court recently awarded Mountain State Blue Cross Blue Shield more than $180,000 for overpayments made to General Practitioner, Dr. Sharooz S. Jamie of Clay, West Virginia. According to the judgment, Dr. Jamie submitted multiple medical claims to the insurer without performing the services billed. In addition to the more than $180,000 in damages, the court awarded $94,000 in interest.

Mountain State personnel identified a potential problem with claims for blood test panels submitted by Dr. Jamie in August 2003. Even though Dr. Jamie 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. Further review revealed that 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.

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. The insurer was ultimately forced to file a lawsuit.

According to J. Fred Earley II, Mountain State's General Counsel, "Mountain State is not in the habit of suing its providers and, in fact, is very reluctant to bring a suit. 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."

In early December 2008, Wood County Circuit Judge J.D. 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 Judge Beane's opinion, "With regard to the incorrect, inaccurate and wrongful billing practices alleged by the Plaintiff (Mountain State), the Defendant (Dr. Jamie) does not, and cannot, dispute that he overbilled the Plaintiff by submitting claims for services and procedures he did not perform."

"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," said Mr. Earley. "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."

About Mountain State Blue Cross Blue Shield
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 close to 1,000 employees in Parkersburg, Charleston, Wheeling and Weirton. To learn more about Mountain State Blue Cross Blue Shield, please visit www.msbcbs.com.