Blue Cross-contracted physicians were recently notified of significant changes to the plan’s medical and reimbursement policies. CMA believes some of the new policies to be in violation of California’s unfair payment practices legislation (AB 1455) and has reported its concerns to the Department of Managed Health Care.

CMA is specifically concerned with Blue Cross’s expanded list of medical policies subject to 100 percent post-service review. Typically, during post-service review, the payor generates a request for medical records. These requests for records generally occur weeks after the initial receipt of the claim. Such reviews create an additional hassle of providing documentation, can significantly delay payment beyond the time frames allowed by law (30 days for PPOs and 45 days for HMOs), and can create a real financial hardship for practices.

Physicians have two options that may prevent this delay. In its communications to the Department of Managed Health Care, Blue Cross has stated that it will accept medical records when submitted with the initial claim. Providing documentation at the time of claim submission can speed up payment for services subject to a mandatory post-service review. However, best practice would be to obtain prior authorization for requested service, even if none is required. According to the DMHC, Blue Cross has indicated it will provide a prior authorization upon request, for these newly listed services.

California’s CMA-sponsored prompt-pay law (AB 1455) prohibits Knox-Keene plans and insurance companies from rescinding or modifying an authorization after the physician performs the service in good faith. This means that once an authorization been given, the physician is guaranteed payment. (For more information, see CMA ON-CALL document #0145, “Payment Denial After Treatment Authorization or Verification of Eligibility.” ON-CALL documents are free to members at http://www.cmanet.org/members. Nonmembers can purchase ON-CALL documents for $2 per page at http://www.cmanet.org/bookstore.)

Physicians should also be aware that under most circumstances, Blue Cross will deny payment for procedures deemed “investigational” or “not medically necessary.” In addition, the Blue Cross contract prohibits billing the patient for a claim that has been denied as not medically necessary/investigational.

Click here for a copy of the Blue Cross notice and the expanded list of procedures subject to post-service review. Physicians are encouraged to carefully review these new policies by visiting the Blue Cross website. Many of these policies are tied to specific diagnosis codes associated with the service or procedure.

Contact: CMA’s reimbursement help line, 888/401-5911.