Blue Cross Blue Shield of North Carolina (BCBSNC) has created and launched a tiered provider network for self-insured employer group Delhaize America, the parent company of Food Lion. The insurer sent letters to gastroenterology, cardiology and orthopedic practices – the only medical specialties currently subject to the tiering process – explaining how the redesigned benefits plan will work.

The letters stated that physicians BSBCNC examined its own claims data to sort physicians into two tiers. Physicians who meet or exceed BCBSNC’s thresholds for both quality and cost receive “designated provider” status. Those who did not meet the selection criteria will not have designated provider status for the 2011 benefit plan year.

According to BCBSNC, Delhaize employees who seek GI, cardiology or orthopedics care, will have different coinsurance amounts depending on the physician’s tier. Services received from designated providers are subject to a 20 percent coinsurance after deductible, while non-designated network physicians must collect 40 percent coinsurance after deductible.

NCMS has also learned the following details about this new methodology:

• The reviewed claims information is only available to physicians/practices that ask for it.
• Reimbursement rates have not changed in conjunction with this program.
• No appeals process is available for status consideration.
• Only Delhaize/Food Lion employees have access to the physician’s tier designation. It is not publicly available on the website or in provider directories.

Both NCMS staff and physician members of the BCBSNC Joint Advisory Group (JAG) have expressed concerns to BCBSNC over the hasty design and launch of the tiered network, the use of claims information as the principal data source, and the general lack of transparency in the process from the physician’s perspective. NCMS continues to follow this issue closely and would be interested to hear of any early experiences from the affected physicians. We will continue to aggressively advocate for our members’ interests as BCBSNC and other payors consider tiering programs.

CLICK HERE to read the letters.