Esq.: You're the man. Thanks for info. nm

[Guest guest]

;-)

Subject: BlueCross/BlueShield, P. Tolton "Legal Division," and Demands for Refund

Dear Doctors: I have seen several letters received by several chiropractic physicians from one P. Tolton "Legal Division" at BlueCross/BlueShield. The letters are crafted in such a way to make you believe that Mr. Tolton is an attorney and that the representations, misrepresentations, accusations, and demands made by this pin-head are somehow based in law. I am not intending to give each or any of you legal advice. However, my general recommendation is that: (1) Realize that P. Tolton "Legal Division" and BlueCross is engaging in a ruse to try to get you to send it money that you have not obligation to send; (2) There exists no legal basis for BlueCross to demand money from you, as far as I believe; (3) Do read the letters from this gentleman, and do spend the time reviewing and considering each of his broad defamatory accusations to make sure that they are not based in fact; (4) At least with regard to letters I have received, I have advised doctors that they should not send any money or agree to send any money; (5) If BlueCrosss threatens to either withhold payment to your clinic or to send payment for future services directly to its insured (I have seen Mr. Tolton threaten to do both), then you should start to use a lien and assignment form which will require BlueCross to pay your clinic in the event it is going to make any payment at all; (6) You may need to start demanding cash payments from all BlueCross insureds.

There is not enough room here to explain to each of you what is wrong with what BlueCross is doing. However, in general, there exists no contract between you and BlueCross. BlueCross' contract is with its insureds, and you are not a party. To the extent BlueCross is owed a refund, it is owed a refund from its insured, not you or your clinic (provided that there was no falsification of records, upcoding, fraudulent billing, etc. as Mr. Tolton may accuse). I have seen at least one example where a doctor called BlueCross to confirm coverage for a particular service (massage), was told that there was coverage, the doctor provided the services, was reimbursed by BlueCross, the doctor continued to provided the services, and now BlueCross demands thousands of dollars that "must be paid by such and such date." Waiver, estoppel, traditional law of equity, and common sense provide, in my opinion, that BlueCross does not have a leg to stand on. If any of you voluntarily agree to an audit of your files at your clinic, then you should have your skull plunged. If BlueCross requests chart notes, by all means send them, but the last time I checked you are owed copying charges. I am not advising you to not cooperate with BlueCross. In more than one instance, I have advised doctors to artfully tell BlueCross to go pound sand. I will prepare a lien and assignment form "for the good of the order" and will post it in the very near future. If this is happening to many of you, I would encourage you to get together and meet and to communicate amongst yourselves. I would be more than happy to attend any meeting. However, the requirements of my practice will not permit me to handle and respond to all the inquiries. I have gladly dedicated several hours already doing just that, and I am willing to help, and I am volunteering to attend the meeting if one is arranged.

One further word of "general suggestion" (not to be taken as legal advice), if it were me, I would not submit to any sort of arbitration, mediation, or appeal process with BlueCross. Agreeing to arbitration or mediation could be taken as a concession (at least by BlueCross) that they have the contractual and/or legal right to be doing that which they are attempting to do. Best Regards, G. , Gatti, Gatti et al, Salem, Oregon