This week the North Carolina Department of Insurance (DOI) informed Blue Cross and Blue Shield of North Carolina (BCBSNC) that the company could not implement a policy that would unilaterally reduce reimbursement rates to providers of certain hi-tech imaging procedures.  The DOI’s decision delivered a momentous win to the medical community by validating the arguments put forth by the North Carolina Medical Society, the North Carolina Hospital Association, and the North Carolina Radiological Society in a joint complaint filed with DOI in October.

The DOI agreed that before implementing such a change to reimbursement, a health insurer must first offer affected physicians and facilities a contract amendment and an opportunity to negotiate new terms.

The dispute was one of the first to involve the application of a new fair contracting law.  That law passed in 2009, and involved a collaborative legislative effort from the NCMS, the NC Medical Group Managers, and a few key state specialty societies. The goal was to end the harmful insurance industry practice of undermining the explicit, negotiated terms of managed care contracts with ever-changing health plan policies and procedures.

In a persuasive Letter of Support to Insurance Commissioner Wayne Goodwin, fifteen medical specialty societies, the NC Academy of Physician Assistants, and the Medical Group Managers underscored the precedential effect that the decision would have, and echoed the request for relief from DOI.

The request for regulatory involvement only came after BCBSNC repeatedly refused to withdraw the policy and follow the proper process at our request.  Given the DOI’s decision, the NCMS is hopeful that health insurers will commit to working cooperatively with the medical community to address our future concerns.

View the NCDOI’s letter to BCBSNC.

See related articles:

Joint Complaint Filed Over BCBSNC Radiology Services Reimbursement Policy (Bulletin, October 28, 2011)

UPDATE: BCBSNC’s Radiology Services Reimbursement Policy Revised and Reposted (Bulletin, October 7, 2011)