JRG: One of the most common examples is that when we perform multiple procedures on patients we do not get paid for each procedure performed. Another example is that we simply don't get paid for procedures performed whether they are part of multiple procedures performed at one time, or not. Finally, we simply don't get paid at the contractual rate for many of the procedures performed.

JRG: We have documented hundreds of instances in which IBC has failed to pay me and my colleague Dr. DiStefano. And our conversations with other orthopedic surgeons in Pennsylvania, through the Pennsylvania Orthopaedic Society, convince me that IBC is doing the same things to all other physicians in this specialty.

JRG: Similar practices are engaged in by some other area insurers, and we have brought a case against Aetna U.S. Healthcare charging similar conduct.

JRG: The financial impact has been quite significant—running to many tens of thousands of dollars in fees unpaid for medical services delivered over the last six years. IBC's downcoding and bundling practices, among other things, make it far more difficult to practice in this market, for the simple reason that a doctor cannot get paid for all of the work he or she does, and does properly, for patients. And IBC controls the majority of patients in this area, so a very large fraction of my practice, and that of all other doctors in this area, is affected by what IBC does.

JRG: Our complaints about reimbursement have met with no response. That's why this suit was necessary.

JRG: No; once we became convinced that negotiations with IBC would lead nowhere, we had no choice but to institute this litigation.

JRG: We're seeking two things: first, we want to get paid, properly, for all of the work we did for IBC's insureds. Second, we want full disclosure by IBC of its actual fee schedules, including any other rules or principles that IBC is going to invoke for determining how much we get paid for the work we do for IBC's subscribers.

JRG: The Society recently moved to intervene in the case in order to help protect the rights and interests of all of its members—the more than 500 Orthopaedic surgeons in Pennsylvania who do business with IBC. The Society has asked the Court's permission to join the case so that it can help press for injunctive relief that will enable doctors for the first time to actually learn the full terms of their contracts, including complete fee schedules and full disclosure of any other payment rules or principles that IBC is going to invoke in determining how much doctors get paid.

JRG: We have recently asked the Court to certify this case as a class action, to proceed on behalf of all orthopaedic surgeons who do business with IBC. It's my understanding that if the Court grants that request, the case will automatically protect the interests of all such doctors. I also understand that, if it were to deny that request, then an orthopaedic surgeon who did business with IBC in Pennsylvania would have to intervene in the case or file their own case in order to protect his or her interests.

JRG: It's very expensive, because of the need for expert analysis of IBC's payment system and because the substance of the litigation is complicated, so the legal analysis is also complex. The group of attorneys now working on the case includes lawyers with experience in the litigation of medical issues as well as lawyers experienced in this kind of complex litigation.