Opinion ID: 742674
Heading Depth: 2
Heading Rank: 1

Heading: facts

Text: 3 Blue Cross is a not-for-profit corporation organized and existing under Alabama Code §§ 10-4-100 to -115 for the purpose of providing health care service plans to subscribers. 1 It furnishes health benefits to approximately 2.2 million people in Alabama, 2 which is more than half of the state's population. 3 4 In order to contain or reduce the cost of providing health care benefits to subscribers, Blue Cross enters into contracts with various health care providers. Providers that have contracts with Blue Cross are known as network providers. Network providers usually agree to perform services for Blue Cross subscribers at discounted rates, and they agree to submit to Blue Cross' quality review, dispute resolution, and cost containment procedures. 5 In its health plans, Blue Cross reserves the right not to honor assignments of benefits. It also reserves the right to choose to pay either the provider or the subscriber, when a subscriber receives medical services from a non-network provider. However, if a claim is received from a network provider for services to a subscriber who has network benefits, Blue Cross will pay benefits directly to the network provider. Blue Cross guarantees that network providers will be paid for their services within a specified period of time; no such guarantee is made to other providers. 6 The Alabama Legislature has forbidden many of the managed care practices that Blue Cross employs, at least when they are utilized by other insurance companies. For instance, in 1984, the Legislature enacted the Dental Care Services Act (the Dental Act). See 1984 Ala.Acts 411. That act prohibits health plans and health insurance policies from denying any dentist's request to become a network provider so long as the dentist is practicing within the scope of his or her license. See Ala.Code § 27-19A-3(2) (Supp.1996). The Dental Act also prohibits a health plan from limiting the patient's selection of a dentist and from reviewing the necessity or quality of any service performed by a dentist. See Ala.Code § 27-19A-3(1), (3) (Supp.1996). It declares void all terms of plans inconsistent with the Act and criminalizes willful violations of it. See Ala.Code §§ 27-19A-5, -8 (Supp.1996). 7 The Pharmaceutical Insurance Coverage Act (the Pharmacy Act), enacted in 1988, see 1988 Ala.Acts 379, prohibits health plans from denying a pharmacist's request to become a provider member of the health plan, so long as the pharmacist is properly licensed. See Ala.Code § 27-45-3(2) (Supp.1996). It also prohibits health plans from limiting a patient's selection of a pharmacist. See Ala.Code § 27-45-3(1) (Supp.1996). 8 The Assignment Act, enacted in 1994, see 1994 Ala.Acts 638, requires all entities providing health insurance or health benefit plans to reimburse, within a specified time period, all health care providers for their performance of covered services. See Ala.Code § 27-1-19(a) (Supp.1996). The Assignment Act also requires insurers or other entities providing health care plans to honor all assignments of benefits, notwithstanding any terms of the insurance or health plans to the contrary. See Ala.Code § 27-1-19(d) (Supp.1996). Health care providers, as assignees, are provided a right to sue to collect the assigned payment. See id. 9 We will refer to the Dental Act, the Pharmacy Act, and the Assignment Act collectively as the Alabama Provider Acts.