Florida dermatologists and Medicare beneficiaries are suing the state's Medicare carrier, HCFA and HHS over a coverage policy that restricts how doctors treat beneficiaries suffering from nonmalignant skin lesions.
The American Academy of Dermatology, the Florida Society of Dermatology and the Seniors Coalition filed a lawsuit last week contending that Blue Cross and Blue Shield of Florida, the Part B carrier, violated Medicare law by requiring physicians to prescribe a chemotherapeutic ointment first when treating lesions in certain cases.
In the suit, filed in U.S. District Court in Jacksonville, Fla., the plaintiffs say the Florida Blues should have factored in local and national practices before setting its policy.
The physician groups had already asked members of the Florida congressional delegation and HCFA to pressure the Florida Blues to withdraw the policy until a national guideline can be developed.
Blues officials said they are trying to reduce a rate of lesion removal or destruction that is three times higher than the national average. They said that high rate suggests Florida dermatologists may be billing Medicare for inappropriate procedures that are preventive or cosmetic.
"We're not 300% closer to the sun," said Sidney Sewell, M.D., the Blues medical director for Medicare.
Under the policy that took effect Nov. 18, unless one of 20 conditions are met, physicians must prescribe the ointment. If the ointment doesn't work, then physicians can attempt more invasive procedures to destroy the lesions.
Because such lesions occur more frequently in older patients and in sunnier climates, the issue has taken on great significance among Florida physicians.
The Blues says the coverage policy will save the Medicare program $975,000 a year. Medicare will pay physicians about $37 billion in fiscal 1997, which began Oct. 1, according to the Congressional Budget Office.
Dermatologists object that the Blues is seeking savings by shifting costs onto beneficiaries. That is because Medicare pays for procedures performed in a doctor's office, but beneficiaries must bear the cost of prescription drugs.
Furthermore, they say the ointment required by the coverage policy may not always be appropriate for Florida retirees. Because it eats away layers of skin to destroy the lesions, the ointment creates raw skin that is sensitive to sunlight and perspiration in Florida's sunny, humid climate.