Texas Doctor Files Case Pro Se in U.S. Supreme Court Against Insurance Giant on Integrity and Unethical...(asonable and medically necessary. ...),Health

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.

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