CMA last week learned that Blue Cross has begun reimbursing patients, rather than physicians, for nonemergency out-of-network PPO services. Letters regarding this policy change, which took effect June 23, went out to brokers and employers but neither patients nor physicians were notified of this change. 

In the past, Blue Cross paid nonnetwork physicians directly for services that were covered under a patient’s benefit plan. Now, Blue Cross will send the patient a check, and the patient will be responsible for paying the physician.

The new policy applies only to Blue Cross PPO products. The insurer’s state sponsored point-of-service and HMO products are excluded from this policy. Also unaffected are small group members covered through Blue Cross Life and Health Insurance Company. However, the direct-pay policy does apply to individual members covered through Blue Cross Life and Health Insurance Company. Blue Cross’s “administrative services only” (ASO) clients with groups of 100 or more have the option to either pay noncontracted physicians or to pay the patient directly.

As you can imagine, it will be very difficult and time consuming for noncontracted physicians to determine when and how they will be reimbursed for services provided to Blue Cross PPO patients. CMA reminds noncontracted physicians that it is best practice to collect directly from patients before the service is provided.

For more information:

• Blue Cross FAQ on this new policy
• Blue Cross memo to brokers on this new policy

Contact: CMA’s reimbursement help line, 888/401-5911 or gfonseca@cmanet.org.