Lindsay Wagahoff, MA | Aug 19, 2020 | 0
BCBSIL Amendment – July 30, 2008
Informational Article Concerning BCBSIL Ammendment Dated July 30, 2008
On July 30, 2008, BlueCross BlueShield of Illinois (BCBSIL) sent its participating providers a Letter Agreement that made changes to its existing provider agreements. At that time, the ICS sent its members a memo explaining the changes. On October 15, 2008, BCBSIL sent its participating providers a new Letter Agreement that rescinds and replaces the July 30, 2008 letter. Some of the changes are similar to those in the previous amendment, but some are new, as detailed later in this memo. The changes outlined in the October 15, 2008 letter go into effect on January 15, 2009, and are not negotiable for providers who remain in the network. In other words, providers’ only options are to take no action and accept the terms or to terminate participation in the network.
Providers who wish to terminate must send written notice with their tax identification number by November 14, 2008, to:
Blue Cross and Blue Shield of Illinois,
Attention: Network Development,
300 E. Randolph Street, 25th Floor,
Chicago, IL 60601-5099.
Notice should be mailed in a way that can be tracked with a receipt confirming delivery.
This information is provided as a clarification to assist ICS members in making a decision regarding their continued participation and is not in any way intended as a recommendation to ICS members either to continue or to terminate with BCBSIL.
The following outlines changes specifically listed in the October 15, 2008 Letter Agreement:
1. Physician Disclosure of Ownership Interest in Facilities —
Where a provider refers a BCBS patient to an outside facility (in or out of network) in which the provider has any ownership interest, the provider must notify the patient in writing.
2. BCBSIL Provider Manual Incorporated into Agreement —
The BCBS Provider Manual is now incorporated into the Letter Agreement and providers agree to comply with all requirements in the Manual. The Manual outlines various BCBSIL procedures and is available online to participating providers.
3. Access to Lab Results —
BCBSIL may obtain laboratory results directly from the lab for tests performed on BCBSIL patients. Under the Clinical Laboratory Improvement Amendment, health plans must obtain physician consent in order to obtain results directly. This provision is intended to provide that consent.
4. Immediate and For Cause Contract Termination –
BCBSIL has expanded its right to terminate a provider. BCBSIL may immediately terminate the agreement if action is taken against the provider’s license for health care fraud as determined by a court of law, or if the license is sanctioned by any state or federal licensing authority. In addition, BCBSIL may immediately terminate the provider “for cause” if it determines there is imminent threat to patient health and safety, “documented abusive billing practices” (not defined by BCBSIL, presumably to be determined by BCBSIL), or misrepresentation of fact by the provider when applying to participate in the network. The latter two grounds for termination –“abusive billing practices” and “misrepresentation of fact” – represent a significant change to the Letter Agreement. The ICS intends to monitor BCBSIL’s implementation of these provisions and strongly encourages members to keep the ICS informed as to any actions taken by BCBSIL in relation to termination on these grounds.
Also, as the ICS has previously informed its members, the parent company of BCBSIL and other BlueCross organizations entered into a settlement agreement in the Thomas-Love class action case, effective April 2008. The language was negotiated between attorneys for Blue Cross providers and the various Blue Cross entities. In addition to changes numbered 1-4 above, BCBSIL also deems that the settlement terms of the class action are incorporated into the Provider Agreement.
ICS counsel has reviewed the settlement document and has noted some of the following provisions:
- Greater Notice of Policy and Procedure Changes – BCBSIL must give 90 days’ written notice to providers if it makes a change that is adverse to providers, and providers will have 30 days from the date of the notice to terminate their participation in the plan.
- New Dispute Resolution Process for Physician Billing Disputes – after the internal appeal process has been exhausted, a physician may submit a billing dispute exceeding $500 to be reviewed by an external Billing Dispute Reviewer regarding issues of coding, downcoding, bundling and appropriate payment. The Billing Dispute Reviewer is to render a decision within 30 days of acquiring all necessary documents and the decision is binding on both the physician and BCBSIL.
- Determinations Related to Medical Necessity or Experimental or Investigational Procedures – A nurse may approve a service as medically necessary, but only a “physician” may deny a service based on lack of medical necessity or being experimental in nature. The policy defines “physician” as an individual licensed as an M.D. or D.O. and does not include a D.C., so the initial determination may be made by a non-D.C. However, providers have the right to file pre- and post-service internal appeals. For appeal purposes, a nurse may grant the appeal but only a “Qualified Reviewer,” or a physician with similar credentials and licensure OR a physician who has experience in treating the same problems as those in the appeal, may deny the appeal. Therefore, it appears that the physician deciding the internal appeal may, but may not necessarily be a D.C. BCBSIL must also establish a process for an Independent Review Organization to conduct an external review following an adverse internal determination.
- Notices Regarding Fee Schedules – BCBSIL agrees to operate standard fee schedules and not to reduce fees more than once per calendar year.
- Medical Necessity Definition — “Medical necessity” is defined as services that meet generally accepted standards of practice, meaning standards based on credible scientific evidence supported by the literature.
- Timelines for Payment of Claims – Claims are to be paid within 30 calendar days from which BCBSIL is in receipt of all information needed for a complete claim, including requested documentation.
- No Automatic Downcoding or Evaluation and Management Claims – BCBSIL may not automatically reduce the code level of evaluation and management codes.
The ICS believes it is important that its members understand the terms governing their managed care agreements and is committed to assisting its members by providing facts to assist in their decision making.