Excellus Settlement

UPDATE: The Excellus Settlement Agreement has officially sunset. However, Excellus has agreed to continue to comply with most of the Section 7 Settlement provisions. See letter of Martin Lustick, M.D., Senior Vice President Corporate Medical Director to David Hannon, M.D., President of the Medical Society of the State of New York, January 2010. 

  • Excellus Settlement Executive Summary

  • Settlement Agreement

  • Exhibits 


  • MSSNY and Excellus Reach Agreement

    In a statement released May 23, 2005 MSSNY and Excellus BlueCross Blue Shield announced that the two parties had reached an agreement in the class action suit filed by MSSNY on behalf of member physicians three years ago. 

    Operational Improvements
    The settlement includes a number of “operational improvements” agreed to by Excellus that focus on prompt payment and adherence to the AMA CPT codes, guidelines and conventions. It also includes medical necessity provisions that take into account “generally accepted standards of medical practice and the treating physician’s judgment.” Excellus also agreed to establish a website that will allow physicians to see fee schedules, clinical editing rules, lists of procedures requiring prior authorization and medical necessity denial rates.

    The company estimates that the value of the improvement is in excess of $50 million and will enable administrative efficiencies “so that more time can be devoted to patient care.”

    Forthcoming Payments
    In addition to the agreed changes in business practices, Excellus has agreed to pay $500,000 toward a per capita payment to retired or deceased physicians as well as set up a $5 million fund for active, practicing physicians to obtain certain in-kind benefits. The company has also to pay $1.25 million towards community health initiatives mutually agreed upon by MSSNY and the insurer, and to pay $250,000 to MSSNY for liability advocacy.