Dr. Dralves Edwards, a board-certified family physician in Dallas, today filed a civil case in the U.S. Supreme Court against Blue Cross Blue Shield of Texas, the contractor for Medicare.
For the past 13 years, Edwards has challenged the integrity and unethical practices of Blue Cross Blue Shield (BCBS) and is confident that the U.S. Supreme Court will rule in a responsible way that every Medicare provider and patient benefits.
In 2003, the original suit was filed in Dallas district court alleging that BCBS engaged in fraud, gross negligence, and criminal acts that, according to Edwards, forced him to close his doors. Today, he works as a hospital emergency room physician.
BCBS responded to the suit by removing it to federal court, but the case was remanded back to district court. BCBS then filed a "No Evidence" Motion for Summary Judgment that was granted sovereign immunity by the lower courts.
Edwards acknowledges that lower court decisions have historically disagreed with well established U.S. Supreme Court cases (i.e., Ardary vs. Aetna; Heckler vs. Ringer; and Kelly vs. Advantage Health, Rochester vs. Travelers).
In 1997, Edwards says BCBS caused irreparable harm to his thriving practice and marred his professional name when he was placed on a 100 percent prepayment review. For three consecutive years, 96 percent of his claims were denied; his practice was 90 percent Medicare.
"I provided free transportation and made house calls that saved Medicare millions of dollars," reports Edwards. "These were patients who probably would have ended up in the emergency room."
In October 1996, Edwards was featured in USA Today as "One of the few doctors in America making house calls."
BCBS denied most of Edwards' claims as "non-covered services and not reasonable and medically necessary."
Medical conditions like breast cancer, diabetes, and decubitus ulcers were denied. However, after the course of five years, claims were appealed through Medicare's administrative process and paid.
"Something was terribly wrong," Edwards says. "Other doctors were being paid by BCBS for these same medical conditions, but payment continued to be denied to me."
Edwards alleges that "BCBS was tested for profiling and got caught."
He explains what happened. One doctor employed by him applied for a new Medicare group number. Dr. Edwards' name was deliberately left off of the original application. The group number was granted, 300 claims were submitted, and BCBS paid 98 percent of them. A month later, Edwards' name was added, 300 claims were submitted and all were denied.
BCBS told Edwards he had a documentation problem. However, after meeting with a Medicare representative to review the denied claims, no problems were discovered. It was recommended that he sign his progress notes and resubmit the claims for payment. He did and they were still denied as "non-covered services and not reasonable and medically necessary."
Edwards then obtained the list of 100 doctors on the prepayment review list for 1997 through 1998. He contacted most all of these doctors and discovered that they knew nothing about a "prepayment review."
"This evidence was highlighted in the suit, but ignored by the courts," says Edwards.
It was becoming apparent that some unethical practices were in play.
To date, this 13-year ordeal has led to thousands of dollars spent; countless hours; a five-year administrative process; five summary-judgment hearings; numerous investigations; nine attorneys; 19 judges; a 100 percent prepayment review; and protectionism from the lower courts.
"Justice for the innocent has not been served," Edwards says. "The guilty remain in business. Right now, it rests in the hands of the U.S. Supreme Court."
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