Physicians Urged to Carefully Review Blue Cross Contract Amendment
[Posted 09/15/08]

Physicians contracted with Blue Cross of California were recently notified of the insurer’s intent to amend its Prudent Buyer contract to include Anthem’s Select PPO product, effective January 1, 2009. CMA reminds physicians that before signing a health plan contract or contract amendment, it is important to know what value it will bring to your practice. Physicians do not have to accept bad contracts or contracts that are not mutually beneficial.

The addendum in question requires contracted physicians to always refer Anthem Select PPO Members to other participating Select PPO providers, unless they have obtained authorization to refer out of network. Physicians should be aware that the underlying Prudent Buyer contract authorizes Blue Cross to unilaterally lower the physicians’ fee schedule as a penalty for referring to out of network providers. For this reason, it is important for physicians to determine if colleagues you frequently refer to and those who refer to you participate in the Select PPO network.

The addendum also requires physicians, in the event they refer patients to a nonparticipating provider, to ensure that the referred-to physician abides by the terms of the agreement.

If you do not want to participate in the Select PPO network, you must notify Anthem Blue Cross in writing no later than December 1. Opt out notices should be sent via certified mail with return receipt to: Anthem Blue Cross, Attn: Select PPO Contract Processing, 2121 North California Blvd., 7th Floor, Walnut Creek, CA 94596.

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. Nonmembers can purchase the toolkit for $100 in the CMA bookstore.

For more information on the underlying Prudent Buyer contract, see CMA’s Blue Cross Prudent Buyer contract analysis, available free to members at the members-only website.

Click here to read the proposed contract addendum.

 Contact: Aileen Wetzel at 916/551-2037 or awetzel@cmanet.org.