Physicians contracted with Blue Cross of California were recently notified that effective July 1 reimbursement for endoscopic procedures, including colonoscopies, will be cut by 20 percent when such procedures are performed in an outpatient hospital environment. Reimbursement will increase by 5 percent for endoscopic procedures performed in physician offices or in Blue Cross-participating surgery centers.

CMA has protested the unilateral change to state authorities, saying the rule places corporate profits ahead of patient care and safety, and is likely illegal. CMA believes that it violates Health & Safety Code §1367(g), which requires that medical decisions be “unhindered by fiscal and administrative management.”

CMA is also concerned that the new policy violates the Knox-Keene access-to-care requirements, as many physicians do not have admitting privileges at Blue Cross-participating surgery centers. Forcing physicians to utilize these surgery centers may also violate the Knox-Keene geographic access rules, which require that covered services be available within 15 miles/30 minutes.

CMA believes the Blue Cross notice violates California’s Provider Bill of Rights, as well. This CMA-sponsored law (AB 1455) requires health plans to give physicians the option to terminate their contract if they do not wish to accept the fee reduction. The Blue Cross notice did not do so.

CMA has reported its findings to the Department of Managed Health Care (DMHC), and the department has given Blue Cross until May 22 to respond to these concerns.

Physicians with specific concerns about patient access or who have difficulty obtaining privileges at a Blue Cross-contracted surgery center can contact Blue Cross’s medical director, Jeff Kamil, M.D., at 818/234-6317 or by mail at 21555 Oxnard Street, AC-6G, Woodland Hills, CA 91367.

Physicians who have been victim of this or other unfair health plan payment practices are encouraged to file a report with DMHC. CMA will certainly continue to advocate on physicians’ behalf, but it is important that DMHC hear individual physician complaints.

For more information on filing a complaint, see CMA ON-CALL document #1051, “Physician Complaints About Managed Care Plans.” These documents are free to members at CMA's members-only website. Nonmembers can purchase ON-CALL documents for $2 per page in CMA's online bookstore.

Contact: Aileen Wetzel, 916/444-5532 or awetzel@cmanet.org.