CMA is urging Blue Cross of California to delay implementation of fee schedule changes due to take effect June 1, because the insurer has failed to make a full and complete schedule available to physicians. This failure has prevented many physicians from assessing the impact that the fee schedule changes will have on their practices.

CMA believes that Blue Cross is in violation of state law, which requires insurers to fully disclose to contracting physicians their fee schedules and payment rules and to notify physicians in writing 45 days before instituting any changes to fee schedules and payment rules.

When physicians were notified in late February of the impending changes to Blue Cross’s Prudent Buyer Plan physician contract, the insurer promised that the new fee schedule would be available on its website by April 15, 45 days before the effective date of June 1. CMA has recently learned, however, that this information will not be available until June 1, leaving physicians without a reasonable means to evaluate the impact of the contract changes to their practice.

The only option available to physicians is to submit by fax the Request for Prudent Buyer Plan Pricing form. Unfortunately, this form only allows physicians to request 10 codes at a time and also requires the requestor to include a description of each code and modifier, and the physician’s customary charge.

"As a practical matter, it is not reasonable to expect a busy physician practice to fully complete the required fields for all services provided, nor is it reasonable to limit the physician to requesting only 10 codes at a time,” wrote Aileen E. Wetzel, associate director of CMA's Center for Economic Services, in a letter to Blue Cross. CMA is particularly concerned that the insurer has not yet notified physicians that the online fee schedule will not be available until June 1.

CMA also believes Blue Cross is in violation of the RICO settlement agreement, in which it agreed to provide greater notice of policy and procedure changes.

To help physicians analyze proposed fee schedules and 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 Nonmembers can purchase the toolkit for $100 in the CMA bookstore.

CMA has also created a financial impact worksheet to help physicians assess the impact fee schedule changes will have on their practices based on their most commonly billed CPT codes.

Contact: CMA’s Reimbursement Help Line, 888/401-5911 or jblack@cmanet.org.