Monday, December 11, 2017

OCMA Blog

Blue Shield makes positive changes to reimbursement policy for physicians treating out-of-network exchange PPO patients

Blue Shield of California recently announced a two-part reimbursement policy change for contracted providers that do not currently participate in the plan's Individual and Family Plan (IFP) PPO product, otherwise known as its exchange/mirror PPO product.
 
Effective with September 14, 2014 dates of services, Blue Shield will implement changes to the out-of-network claims payment process and will now reimburse providers directly when PPO exchange/mirror product patients are seen out of network. Previously, Blue Shield issued payment directly to the patient. The notice also states that out-of-network physicians may continue bill patients for the balance of billed charges.
 
Additionally, for Blue Shield contracted providers who see Blue Shield PPO exchange/mirror patients out of network, the plan will process payment based on the provider's PPO contracted amount. Please note out-of-network benefit rules will still be applied, meaning the patient will still have the same out-of-network cost sharing. Previously, Blue Shield processed out-of-network PPO claims based on the reimbursement rate for its IFP product, which is typically discounted from the PPO rate.
 
The policy change does not affect services provided to patients with a Blue Shield IFP EPO plan, as there are no out-of-network benefits with an EPO product.
 
Blue Shield reports the policy change is in response to provider feedback of difficulties collecting from exchange/mirror patients they have seen out-of-network. The policy change also brings its physician payment rules in line with Blue Shield's facility payment policy for PPO exchange/mirror patients who are seen out of network.
 
CMA believes the policy change will be positive for physicians and commends Blue Shield for their responsiveness to provider concerns.
 
To view the Blue Shield notice, click here.
 
Physicians with questions about the policy can contact Blue Shield Provider Information & Enrollment at (800) 258-3091. OCMA members can contact Mitzi Young, OCMA Physician Advocate at (888) 236-0267 or myoung@cmanet.org

Blue Shield Recontracting Effort Expanding to Orange County

Earlier this year, Blue Shield began recontracting with physicians across the state. The California Medical Association (CMA) has learned that physicians in Orange County will be next to see the new contracts.

Blue Shield has assured CMA that if a physician chooses not to sign the new agreement, his or her participation status with Blue Shield will not be affected.

The reason for the recontracting initiative, according to Blue Shield, is twofold: 1) Blue Shield has not done a large scale recontracting with physicians in over a decade, so the new contracts will allow Blue Shield to ensure consistency and compliance with new laws and regulations; and 2) Blue Shield is offering various tiered networks based on price point in anticipation of possible participation in California's Health Benefit Exchange.    

CMA continues to work with exchange stakeholders to address significant concerns regarding the exchange grace period, monitoring of network adequacy and clinician-level performance measurement in qualified health plans offered in the exchange.

Exhibit A of the new Blue Shield contract allows physicians to designate which products they are willing to participate in by product type.

While Blue Shield did update its fee schedule statewide on July 1, there is no fee schedule change associated with this recontracting initiative, with the exception of the Direct Contract HMO Medicare Advantage product.

Physicians are encouraged to carefully review and understand the vast range of legal and practical implications associated with the execution of any new contract and new product types. To assist physicians, CMA has completed an  analysis of the new Blue Shield contract, which is available to members in CMA's online resource library at  http://www.cmanet.org/resource-library.

For additional information on evaluating and negotiating complex managed care contracts, see CMA's contracting toolkit, "Taking Charge: A step by step guide to evaluate and prepare for negotiations with managed care payors."The toolkit is also available free to members in CMA's resource library.

The notice  directs physicians with questions about the new contract terms to contact Blue Shield Provider Services at (800) 258-3091.

Questions: CMA at (888) 401-5911 or economicservices@cmanet.org.


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