BCBS going to single payor?

[Pain Applicant1]

I contacted to BCBS today. They say that during their next fee schedule adjustment in a year or so negotiation will not be possible. All will be paid the same. Anyone else come across this?

I like this as I'm on my own and I don't have the power to negotiate. It's a take it or leave it situation. They lowered my reimbursement once I lost my PHO and I don't like that bigger institutions have a stronger hand in negotiation than me due to higher physician numbers. Of course, I didn't mind this before the PHO dissolved.

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[ampaphb]

They will be forced to back down. Too many large groups can exert market power. If a group represents a high enough percentage of the relevant specialty in a community, BCBS will be forced to negotiate, or risk losing a large percentage of their customer base. It's basically a game of chicken.

 

[Disciple]

I contacted to BCBS today. They say that during their next fee schedule adjustment in a year or so negotiation will not be possible. All will be paid the same. Anyone else come across this?

I like this as I'm on my own and I don't have the power to negotiate. It's a take it or leave it situation. They lowered my reimbursement once I lost my PHO and I don't like that bigger institutions have a stronger hand in negotiation than me due to higher physician numbers. Of course, I didn't mind this before the PHO dissolved.

I'm not following. BCBS doesn't usually negotiate with solo/small practices.

That's what the PHOs/IPAs are there for. To get better rates for their member physicians.

If the PHO dissolved, then of course BCBS has the upper hand.

 

[olafa]

I'm not following. BCBS doesn't usually negotiate with solo/small practices.

That's what the PHOs/IPAs are there for. To get better rates for their member physicians.

If the PHO dissolved, then of course BCBS has the upper hand.

this happened in my area also. The IPA in prior years has negotiated a rate higher than what was standard nationally, now they say they are not going to renew w the IPA. The IPA did not dissolve, however is now up to individuals and that comeback rate is not much higher that MC and blues are not a major portion of my patient population . They say if you opt out - it is opting out for all plans. Which is what I may do, out of network might be better! Do you think there is room for negotiation when they imply "no-negotiation...?" They are such a big company any may not care what the little guys do anyway.

 

[Yo GabbaPentin]

They have rapidly become our worst payor. They deny everything even when all of their buzzwords are in the note. Last week I did a peer to peer with some "doctor" on their end. He approved the procedure when I essentially read my note back to him. Bcbs then denied ever approving and repeatedly told the patient I never called. The only positive of bernies medicare for all would be to watch them all close up shop.

 

[Dr. Ice]

They have rapidly become our worst payor. They deny everything even when all of their buzzwords are in the note. Last week I did a peer to peer with some "doctor" on their end. He approved the procedure when I essentially read my note back to him. Bcbs then denied ever approving and repeatedly told the patient I never called. The only positive of bernies medicare for all would be to watch them all close up shop.

Agree..horrible to deal with. Deny deny that's all they do. Everyone's gotta do 6 weeks of PT for no reason and take 4-6 weeks of NSAIDs even if they have a contraindication or intolerance. It's a joke. They deny for not saying "fluoroscopic guidance" even if the patient already had the procedure done previously with success.

 

[Disciple]

this happened in my area also. The IPA in prior years has negotiated a rate higher than what was standard nationally, now they say they are not going to renew w the IPA. The IPA did not dissolve, however is now up to individuals and that comeback rate is not much higher that MC and blues are not a major portion of my patient population . They say if you opt out - it is opting out for all plans. Which is what I may do, out of network might be better! Do you think there is room for negotiation when they imply "no-negotiation...?" They are such a big company any may not care what the little guys do anyway.

Based on limited information, this situation sounds worse than the OP's situation, where the PHO dissolved.

If the carrier won't renew with the IPA, it could be a sign that the clout or numbers of independent physicians in the community is dwindling, or that the strength of the insurance carriers/hospitals in the area is growing.

 

[lonelobo]

I'm not following. BCBS doesn't usually negotiate with solo/small practices.

That's what the PHOs/IPAs are there for. To get better rates for their member physicians.

If the PHO dissolved, then of course BCBS has the upper hand.

For clarification IPAs are not allowed to negotiate rates for members this is a FTC vioalation! They can agree to an overall "boilerplate contract" for practices, but practices negotiate the RATES with the insurer using the IPA as a Messenger.
If an IPA is set up like an ACO and all the practices are integrated , Then the IPA can discuss rates

 

[Pain Applicant1]

I'm not following. BCBS doesn't usually negotiate with solo/small practices.

That's what the PHOs/IPAs are there for. To get better rates for their member physicians.

If the PHO dissolved, then of course BCBS has the upper hand.

Was in a PHO = high reimbursement
PHO dissolved = decent reimbursement

Once PHO contract expired Blue changed my fee schedule and told me to take it or leave it. I took it. I'm thinking about joining an IPA but don't want to pay them for services I don't need. I contacted Blue to try and explain that their lower fees will push me to an IPA which won't be beneficial for either one of us. Blue told me that when new fee schedule comes out they will not negotiate with anyone, IPA, individual, etc, does not matter. My PHO worked through the law and legally negotiated rates. It was essentially a union without legally being a union. However, UHC would not participate with the PHO and now it seems BCBS is doing the same thing.

 

[Disciple]

My understanding of how IPAs work, is that the IPA assumes the financial risk, instead of the insurance company. I.e. the IPA contracts with insurance companies, who give X dollars to provide services to patients. The IPA then contracts with individual doctors/practices and does the pre-certs, fee-for-service payments, etc., and distributes any shared savings.

 

[lonelobo]

My understanding of how IPAs work, is that the IPA assumes the financial risk, instead of the insurance company. I.e. the IPA contracts with insurance companies, who give X dollars to provide services to patients. The IPA then contracts with individual doctors/practices and does the pre-certs, fee-for-service payments, etc., and distributes any shared savings.

That is not what an IPA does, what you describe is more of an ACO

Our IPA has about 400 Physician members.
The IPA comes to an agreement on a Boilerplate contact with the insurers such as United, Blue plans,etc
these contracts should be scrutinized well and this is the Great thing that an IPA should do.
Once this contract is finalized then the IPA sends out ballots to providers and provider groups to negotiate rates, The IPA cannot negotiate rates
for individual members. When there are disputes such as timely payment from a payor or other things mentioned in Boilerplate contract, this is when IPA advocates on the part of the provider.

 

[Stim4me]

you are more likely to negotiate with cigna, Aetna, and united. BCBS is in bed with the government and supports a single payor system. Aetna and United are the opposite.
hospitals routinely get 40% more than pp. I am working on eliminating second and third level reimbursement deductions (tfesi, RFA's, facets) with some of these insurances currently. you have to continueto negotiate your contracts as best as you can and optimize you revenue. laziness is ones demise.... you may have to go out of network with BCBS someday.