Blue Cross, N.C. providers at odds over imaging reimbursement cuts

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In the war over reimbursements, a battleground has developed in North Carolina, where the state’s largest health insurer is pursuing a 50 percent reduction to the technical component fee for multiple image procedures amid outcry from many of the state’s providers.

In June 2011, Blue Cross and Blue Shield of North Carolina notified radiology providers that the technical component fee for second and subsequent images performed during the same outpatient session would be subject to a 50 percent reduction, similar to a reimbursement policy created by Centers for Medicare & Medicaid Services (CMS).

Physicians and hospital lobbyists and associations, including the North Carolina Hospital Association, challenged the move by saying it ran afoul of a 2009 law covering provider contracts, according to a report by the News & Observer. In December 2011, the North Carolina Department of Insurance agreed with providers, prompting an appeal by Blue Cross.

“We reach a lot of agreements with these providers on a whole variety of things and this is one where we have a bit of a standoff and the issue still remains, which is why we asked for a public hearing,” said Lew Borman, a spokesman for Blue Cross, in an interview with Health Imaging.

Borman said Blue Cross’ position is that billing multiple times for services and items received once is unreasonable. Technicians greeting patients, the handling of consent forms, room prep and many other activities that are covered in the technical component fee are only completed once, no matter how many images are taken in the session. Bills for these services add up, and Borman said last year the cost of multiple billing exceeded $16 million.

“This is not about quality; this is about cost and about this particular technical component. The individual does not walk into the room three times…they shouldn’t be billed multiple times for the services they receive just once,” said Borman.

But providers argue that making changes to reimbursements undermines current contracts and past negotiations.

“By unilaterally issuing a policy to change these reimbursement rates, Blue Cross is circumventing both the negotiating process and the current law,” read a statement provided to Health Imaging by the North Carolina Hospital Association (NCHA). “The law was passed in 2009 to address this very type of issue: to prevent insurers from unilaterally changing the reimbursement terms of a contract.”

The statement notes that while CMS has adopted a similar policy for Medicare, the comparison is not apt because CMS doesn’t negotiate with providers like a private insurer.

“Nothing in state or federal law or regulation or elsewhere requires Blue Cross or any other insurer to agree to pay a provider any particular amount for any service. But once an insurer agrees in a contract with a provider to pay under certain terms, it can’t use a Medicare policy to avoid paying what it has agreed to in the contract, and it cannot unilaterally amend the terms of that contract,” argued NCHA.

Currently, there is no date set for the hearing of Blue Cross’ appeal, according to Borman.

Update: A previously released of this story mistakenly credited the statement from the North Carolina Hospital Association to the North Carolina Health Access Coalition.