BCBSNC Pursues Appeal of DOI Decision on Multiple Radiology Reduction Policy

A few months ago, the North Carolina Medical Society, NCHA, and the NC Radiology Society jointly petitioned the NC Department of Insurance regarding BCBSNC’s move to implement a new radiology reimbursement policy in a way that we believed violated state law. The DOI agreed and instructed BCBSNC that, in order to implement the policy, the insurer must first follow a formal process for amending its contracts with affected physicians and facilities. Review that story here.

Since then, BCBSNC has appealed the DOI’s decision to an administrative hearing officer.  Quickly after BCBSNC filed its appeal, the NCMS, NCHA, and NCRS requested to intervene in the case and were granted full-party status by the Hearing Officer.  As full parties, the three organizations will help the DOI defend its position that BCBSNC must follow the fair contracting statutes before implementing the radiology policy.  The appeal is still pending.

In an interesting twist, BCBSNC Network Management simultaneously issued proposed contract amendments to radiology providers in the network, seemingly in compliance with the DOI’s initial decision and relevant state laws. This was also what the NCMS, NCHA, and NCRS had been asking – and then pushing – BCBSNC to do all along.

In its written notice to affected practices, BCBSNC disclosed that it would implement the radiology policy in April 2012. Physician practices and facilities in receipt of this notice should know that, at this point, the outcome of BCBSNC’s appeal at DOI will likely have no effect on the proposed contract amendment that you may now be considering.

BCBSNC has indicated to us that its contracting effort does not change their intention to pursue an appeal of DOI’s decision. This is unusual, though, since the original decision instructed BCBSNC to comply with the statutes before moving forward, and it now seems like they have.  This paradox was the basis for a Motion to Dismiss the Appeal that was filed by DOI this week and will be supported by the three provider organizations.

Check back for additional updates on this issue from NCMS.


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