BCBS and Orthonet – December 2012

BCBS and Orthonet – December 2012

Updated December 27, 2012 – Many of you are aware of the announcement from Blue Cross Blue Shield of Illinois regarding their contract with Orthonet to perform Utilization Management across the state of Illinois, to commence sometime in 2013.  If you are not aware, please read the article in the October 2012 BlueReview [link needed for completion].

The Illinois Chiropractic Society always advocates avidly on your behalf to the fullest extent that the law will allow.  We must remind our members that antitrust law is very rigorous, so we would encourage all physicians to be extremely cautious during this time to avoid any accusations that might be viewed by regulators as antitrust violations.  The Illinois Chiropractic Society reminds all doctors that state and federal antitrust laws prohibit agreements among competitors that unreasonably restrain competition. 

 Charges of antitrust violations are often based upon discussions among competitors regarding prices, price levels or price mechanisms, and also include agreements to participate or not participate in any network agreement.  The FTC recently investigated and entered a consent order and fine against two chiropractic related organizations for such activities.  Antitrust violations can occur at formal and informal meetings, over the phone, via email, and many other forms of communication.  The ICS does not condone or participate in any such discussions, and we strongly urge our doctors to practice the same restraint. 

First, we want to make sure that all of our doctors know that the ICS is aware of, has been, and will continue working on this issue.  We have had several conversations with BCBS, including a meeting held last Wednesday, December 19, 2012.  Additionally, BCBS-IL has released some clarification to the ICS in writing.  The most up to date FAQ from BCBS can be found here.

Although ICS is continuing to seek additional information, we have received the following important points of clarification:

Which patients will be affected by the initial program?

BCBS has indicated, “Initially the program will apply to BCBSIL PPO members who are fully insured.”  According to the Employee Benefit Research Institute, “In a fully insured plan, the employer pays a per-employee premium to an insurance company, and the insurance company assumes the risk of providing health coverage for insured events.” Roughly 45% of insured patients are fully insured.  However, BCBSIL has indicated that the program may be expanded to other plans after the initial period.

What provider types will be affected by the program?

BCBS informed the ICS, “All independently contracted professional PPO providers providing the following outpatient physical medicine services will be included in the program: Chiropractic services, Occupational therapy (OT), and Physical therapy (PT).”


According to BCBS, all independently contracted health care providers will be required to comply with this policy.  All PT, OT and chiropractic services provided by any provider (MD, DC, DO, PT, OT, etc.) will be subject to these program guidelines.  For example, a medical doctor providing physical medicine services will be subjected to the same tiering and potential pre-authorization as chiropractic physicians. Additionally, non-physical medicine services provided by chiropractic physicians will not be subjected to tiering or pre-certification.

NEW: Facilities (i.e. hospitals) offering these services are not required to comply with the program.  However, hospital-owned practices will be included in this program.

Will all chiropractic physicians be subject to the same rules?

“BCBSIL contracted providers will initially be assigned to a tier level based upon utilization patterns of two years of historical PPO claims. The tiering protocol for the outpatient rehabilitation management program is designed to identify the providers who have previously demonstrated, and those who continue to demonstrate, practice patterns that are generally within the norm for the same and similar provider types. Providers will be tiered based upon their practice patterns as compared to the norm. Providers will be notified of the findings and given an opportunity to submit information if they disagree with their classification. Provider pre-authorization responsibilities will vary, based upon practice patterns, with greater responsibilities required of providers who appear to fall outside the norm.”

NEW: Although the information contained in their written FAQ does not address the tiers specifically, representatives from the Network Management division with BCBS-IL told the Illinois Chiropractic Society providers would be categorized into three tiers.  They informed us that one tier of physicians (and other health care providers) would see no change in their practice (i.e. would have no precertification requirement) and would represent approximately 20%.  Based upon the two-years of considered claims data, BCBS would place approximately 60% of health care providers into the second tier requiring pre-certification after the 8th visit.  However, BCBS-IL would place “outliers” into the remaining one tier under which these providers would be required to precertify treatment, beginning with visit number two.  Based on the information shared with the ICS, only visits where physical medicine services are rendered will be included in the pre-certification requirements and considerations.

When will we know specifics such as which tier will be assigned to us, when the program will begin, how to appeal our tier, etc.?

BCBS will communicate 90 days prior to the program initiation as follows: general information via the BlueReview and physician specific information via letter.

Will precertification be handled by phone, fax, or online?

It seems that many of the details are either yet to be determined, or have not been released yet.  However, the ICS was told that precertification by fax would definitely be an option and online and phone precertification was being investigated.

NEW: The Illinois Chiropractic Society requested that BCBS develop the program without including additional paperwork for our physicians. Additionally, we requested that BCBSIL identify the specific documentation attributes (beyond general documentation standards) that Orthonet will expect or require for pre-certification approval.  It is our intention of providing our members with the greatest amount of information to appropriately provide care to your patients.  The ICS will keep members informed of any such information provided by BCBSIL.

NEW: BCBS indicated the turnaround time for pre-certification will fall between 24 and 48 hours.  We stressed the importance of a fast turnaround for your patients and their members, and we encouraged a time frame closer to 24 hours.

Will providers be required to re-contract with Orthonet?

No. The contract, claims processing, and member benefits will continue to be managed by BCBS-IL.  Orthonet will be responsible for the pre-certification.

We are working diligently to obtain the following specific details of this new program from BCBSIL: 1) how to determine which patients will require pre-certification, 2) tier appeal process, 3) Orthonet’s chiropractic experience, 4) documentation and paperwork demands, 5) why hospital facilities will be exempt, and more.

The ICS believes it is absolutely critical that we obtain these points of information in order to understand the full impact of the change and to determine our best course of action.  We appreciate our members’ understanding that we are continuing to gain clarification, after which we will formulate an appropriate response within the confines of the law.  Additionally, please keep your profile information up to date and subscribe to the Illinois Practice Edge to ensure that you are receiving the alerts from the ICS, as we anticipate developing patient education materials regarding these changes.

Thank you for your patience during our investigation and discussions with BCBS and Orthonet.  As always, we will bring information to our members as quickly as possible.

About Author

Marc Abla, CAE

Marc Abla began working at the Illinois Chiropractic Society in 2002 and became the Executive Director in 2008. He brings his extensive financial, administrative and association experience to the ICS. He is a Certified Association Executive and a graduate of the Certified Leadership Series through the Illinois Society of Association Executives. Additionally, he is a member of the Illinois Society of Association Executives, the American Society of Association Executives, Association Forum, Congress of Chiropractic State Associations, and the American Chiropractic Association.Online CME CoursesConnect

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