CMA has received a number of calls from physicians upset that they had been automatically opted into Blue Cross’s Medicare Advantage Regional PPO, Freedom Blue. Physicians should be aware that even though Blue Cross does have an “all products” clause in its Prudent Buyer contract, the plan agreed as part of its RICO settlement with CMA that it would not require physicians to participate in its Medicare Advantage or Medi-Cal network. Physicians who do not wish to participate in these networks can opt out by notifying Blue Cross in writing.

The all products clause in Blue Cross’s Prudent Buyer contract authorizes the plan to automatically include all contracted physicians in any of its current and future products, including Medicare/Medicaid products. Contracted physicians who treat Freedom Blue patients will be reimbursed at Prudent Buyer rates rather than at Medicare rates.

To opt out, you must notify Blue Cross in writing that you are exercising your rights pursuant to 7.13 (b) of the RICO settlement not to participate in its Medicare and/or Medicaid product networks. More information, including a sample letter you can use to opt out of Blue Cross’s Medicare/Medicaid products, can be found in CMA ON-CALL document #0152, “Medicare Managed Care/Medicare Advantage.” 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.

CMA reminds physicians that before signing a health plan contract, it is important to know what value that relationship will bring to your practice. Physicians do not have to accept bad contracts or contracts that are not mutually beneficial. Physicians are advised to review payor fee schedules carefully to ensure that the proposed compensation is sufficient to maintain a medical practice.

To help physicians negotiate and manage complex third-party payor agreements, CMA has published a contracting toolkit, “Taking Charge: Steps to Evaluating Relationships and Preparing for Negotiations—A Focus on Payor Contracting.” This toolkit is available free to members at the members-only website (click on “Reimbursement Advocacy” under “Physician Advocacy”). Nonmembers can purchase the toolkit for $100 in the CMA bookstore.

Contact: CMA’s Reimbursement Helpline, 888/401-5911.