Doctor Groups Sue BCBS Over Low Reimbursements

A group of hospital care providers in Arizona are suing the state's largest medical insurer, claiming Blue Cross Blue Shield has been improperly paying them as in-network providers and depriving them of dispute resolution through a new federal law.

Four health care groups representing over 300 doctors at 10 Arizona hospitals brought their action to federal court, alleging that Blue Cross and Blue Shield of Arizona Inc. has been abusing its position in the private insurance market to force them into lower reimbursements ever since the groups left Blue Cross' network (terminated) over low reimbursements.

Even after terminating the unfair contracts, these providers claim they were still paid as in-network providers, under the outdated contracts, resulting in lower payments.

Providers involved also argue that Blue Cross has deprived the doctors access to the Informal Dispute Resolution (IDR) process in an attempt to avoid the No Surprises Act (NSA).

The lawsuit seeks to enjoin #BCBS from paying the group under individual #physician #contracts, treble damages and a court declaration that Blue Cross cannot pay provider groups under individual contracts.

Background

The groups filing details a yearslong saga with the insurer over payments. Two of the groups had been in-network with Blue Cross for years, but in 2021, the providers began to demand bigger reimbursements, claiming that the insurer had been paying below the market rate.

For 10 months, the providers said, Blue Cross ignored their calls to renegotiate until finally responding with a proposal that would have actually cut the reimbursement rates.

With negotiations going nowhere, the doctor groups and Blue Cross ended their in-network contract. But the providers said that even as they continued to try to negotiate in good faith for a new contact, their reimbursement rates for Blue Cross patients dropped even further and were still paid as in-network providers.

BCBS Response

According to the plaintiffs, many of the individual physicians in the groups still had network relationships with Blue Cross dating back to when they first began practicing. And even though the four doctor groups were billing the insurer using the out-of-network group identification number, they were reimbursed under the outdated individual physician contracts.

The four hospital-based physician groups call Blue Cross' workaround (response) "absurd" and retaliatory and say it's an effort to avoid the federal No Surprises Act, which took effect last year. The?new law established?an independent arbitration process for settling disputes between out-of-network providers and insurers but has no such process for in-network disputes.

The physician groups said, Blue Cross told them that if they terminated the individual physicians' contracts, Blue Cross would end any contracts with other provider groups that employ the doctors, as many physicians work under multiple provider networks.

The case is Cogent Healthcare of Arizona PC et al. v. Blue Cross and Blue Shield of Arizona Inc., case number 2:23-cv-02119, in the U.S. District Court for the District of Arizona.

Reducing Low Reimbursements

Once you sign a contract, or fail to do so, kicking the contract into ‘evergreen’ mode, the race starts. If that happens and you haven’t properly reviewed or negotiated your payer contracts, how can you expect an optimal result?

While understanding healthcare payer contracting can be laborious and time-intensive, it truly is critical to ensure the timely and correct reimbursement that reduces the chance of claims being denied, thus maximizing reimbursement.

Understanding the contract is a preface to performing well within it and adequate performance within payer contracts is key for the physician, the patient and the medical practice.

In short, payer contract management refers to a host of efforts toward improved performance within contracts, with increased revenue as a result.

Of course, doing all of this is easier said than done. Indeed, many healthcare organizations have and continue to shy away from payer contract optimization, simply due to its daunting nature and the pressing nature of other priorities.

Summary

Your revenue cycle begins long before a patient walks in the door. While many organizations fail to recognize it, the starting line is payer contract management.

The CodeToolz Contract Analyzer Reduces the Burden of Managing Managed Care

Our hard work and common-sense solutions deliver cost effective results that reduce the burden of managing managed care. We continually use our decades of experience and knowledge to find new ways to help our health care clients improve contract language and reimbursement.

Let the experts at CodeToolz take your contracting efforts from burden to competitive advantage. Contact Us Today (512) 787-1852. Schedule Your Fee Consultation / Demo here.