Blue Cross sued over payment policy
Payments to increase for nonhospital endoscopies
The California Hospital Association has sued Blue Cross of California to stop a new payment policy that decreases reimbursement for endoscopic procedures that are performed in hospital outpatient departments and boosts payment when the procedures are performed in physician offices and freestanding surgery centers.
The lawsuit claims that Blue Cross is violating state law by given incentives to physicians to make medical decisions based on financial considerations. The new policy will penalize physicians who perform colonoscopies in a hospital outpatient facility by cutting their payment by 20%, according to the hospital association. If the same procedure is performed in a physician's office or freestanding surgery center, Blue Cross will give the physician a 5% bonus, in addition to the full fee.
The suit claims that Blue Cross also is violating provisions of the state's insurance code and the Knox-Keene Act. These provisions, which regulate health plans and insurance companies, not only require doctors to make medication decisions unhindered by financial concerns, but also make it unlawful to provide financial incentives to reduce, deny, or limit services, the association says.
Also, the suit claims that Blue Cross is committing fraud because it tells members they have a choice of health care providers within the plan's network, but that choice is being severely limited, the association says.
The suit is seeking an immediate injunction to prevent Blue Cross from implementing the plan. At press time, the new policy was scheduled to take effect July 1.
In a letter addressed to Blue Cross of California, John C. Lewis, executive vice president/CEO of the California Medical Association, said, "Physicians and their patients, not health plans, are in the best position to make medical decisions, including the most appropriate site of service based on each individual patient's medical circumstances." Additionally, Lewis pointed out that many physicians don't have privileges at the ambulatory surgery centers (ASCs) that Blue Cross has presented as options, and many of those ASCs are not accepting new applications for medical staff membership. "In order to avoid Blue Cross' penalty, physicians will be forced to refer their own patients to a participating physician that has medical staff privileges at one of the Blue Cross designated ASCs," he says. "The patient/physician relationship is disrupted and continuity of care may be adversely impacted."
The California Hospital Association has sued Blue Cross of California to stop a new payment policy that decreases reimbursement for endoscopic procedures that are performed in hospital outpatient departments and boosts payment when the procedures are performed in physician offices and freestanding surgery centers.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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