A federal settlement that helped create a fair insurance contracting process has expired for most Pennsylvania Blue Cross and Blue Shield plans, and Pennsylvania physicians are already noticing insurers reverting to unfair contract language.
Legislation is necessary to ensure that the provisions of the original settlement, known as the Love settlement, continue to protect physicians.
One-sided contracts force physicians to make a tough choice: either sign a contract with unreasonable provisions that lead to reimbursement issues and administrative hassles, or say no to the contract and lose many of their patients. Both choices create a difficult situation and have the potential to severely damage the physician-patient relationship and affect the financial viability of medical practices.
That’s why the Pennsylvania Medical Society is supporting a bill to create fair contracting.
“Simply put, House Bill 1763 is the Love Settlement,” said Marilyn Heine, MD, president of the Pennsylvania Medical Society (PAMED), in testimony before the House Insurance Committee on Nov. 29, 2011, in support of the bill.
“We are already seeing in a number of physician contracts strong indications that the Blues are setting the ‘contractual stage’ to revert back to their old practices of taking unfair advantage of physicians and their patients.”
Like the Love settlement, HB 1763 would require health insurers to:
- Openly share which physician services and supplies require precertification or advanced permission to provide care and honor their precertification decision after the care has been provided
- Provide complete fee-schedule amounts to physicians
- Give physicians 90 days notice before they make any changes to physician contracts
- Disclose to physicians any adjustments or significant edits that are implemented through their billing software
Also like the Love settlement, HB 1763 would prohibit health insurers from using “all products” clauses in contracts with physicians and changing or lowering payment for care already provided to a patient. It would statutorily define and clarify the definition of “medical necessity.”
Contact your legislators and urge them to support this bill.
“The manner in which health insurers ‘game the system’—to the detriment of medical practice’s economic viability and the patients whom we serve—is unacceptable,” said Dr. Heine. “The time has come to mandate that the Blues continue following the contractual guidelines set in the Love Settlement.”
| In 2007, citing unfair provider-insurer contracts, North Carolina physician Thomas Love won concessions in a federal lawsuit against Blue Cross and Blue Shield of North Carolina. The result was an agreement known as the Love Settlement, which Pennsylvania’s Blues Plans also signed. While the agreement has had positive effects on physicians and patients, it was limited to four years from the date of federal court approval. For Independence Blue Cross, Blue Cross of Northeastern Pennsylvania, and Highmark, their agreements have already expired. For Capital Blue Cross, their settlement agreement will expire within the next year. |