BCBS
policies add unnecessary administrative costs to the health care system
ST. PAUL – The
Minnesota Hospital Association (MHA) today asked state regulators to
investigate Blue Cross Blue Shield of Minnesota (BCBS) for recent policies
and practices that are harming Minnesota’s hospitals and clinics and their
patients with BCBS insurance.
On behalf of its 141 hospital
and health system members, MHA is asking the Minnesota attorney general and
the commissioners of the Minnesota Departments of Commerce and Health to
review BCBS’s refusals to pay for certain medically necessary services its enrollees
receive at hospitals even though the hospital and providers are in-network.
The association also asked the state officials to examine dramatic increases
in services requiring prior authorization that are delaying patient care and
denying payments for medically necessary services.
“Recent actions by Blue Cross are coming between
physicians and their patients, delaying necessary medical care and driving up
the cost of health care in Minnesota,” said Lawrence J. Massa, president and
CEO of MHA. “MHA and our members sought multiple collaborative approaches to
resolve these issues and correct BCBS’s actions. But the harms continue and
are growing, so it is time for the state to determine if the insurer is
violating longstanding consumer protection laws.”
BCBS has dramatically increased the number of services
it will not cover or pay for without a prior authorization before patients
can receive necessary medical treatment, according to MHA. These requirements
cause physicians and patient advocates to spend countless hours navigating
online forms and waiting on hold for BCBS’s subcontractors to respond to
their calls. Then, it can take days or as much as two weeks for BCBS to
authorize the service the patient’s doctor ordered. These delays and
burdensome bureaucratic gauntlets interfere with the doctor-patient
relationship and cause patients and their families to suffer and worry longer
than necessary.
“BCBS has admitted that an extraordinarily high
percentage of requests for prior authorizations are eventually approved. In
other words, in the vast majority of situations, physicians and patients are
making appropriate, evidence-based decisions to get medically necessary
care,” said MHA’s letter to state officials.
“This simply adds administrative costs to our health
care system,” Massa said. “Both BCBS and health care providers are now
spending a lot more time and money on these administrative processes and
complications – money that would be much better spent on actual patient care
or reducing the costs of insurance for individuals and employers.”
In addition, MHA specifically cited a new BCBS “site of
service” policy implemented earlier this year in which it will no longer pay
for colonoscopies performed at certain hospitals based on where the hospital
is located. This change restricts Minnesotans’ access to critical services
used to identify colon cancer and other diseases, while health care
professionals, including the Minnesota Department of Health, have been urging
people to have these screenings to prevent loss of life as well as lower the
costs of treatment by diagnosing cancer earlier.
To the best of MHA’s knowledge, BCBS has not informed
the people it insures about these changes, or that they cannot go to an
in-network hospital and receive care from an in-network doctor for a covered
service under their policy.
In its letter sent to state regulators, MHA cited the
following impacts a result of BCBS’s policies:
- Restricted access to lifesaving health care procedures
- Delays in receiving needed care
- Unnecessary burdens, including having to change providers, imposed
on individuals and families
- Limited health care resources being unnecessarily diverted to
administrative and legal burdens rather than patient care
- Lost revenues for already struggling hospitals and clinics
- Exacerbating clinicians’ growing sense of burnout
Further, a health care provider who complies with all
of BCBS’s requirements, navigates all of its hoops and eventually gets prior
authorization for the service can still have its claim for payment rejected
by BCBS, MHA said. Ordinarily, a provider would be able to appeal that
decision and show the insurer that it made a mistake and needs to pay the
bill, but in some cases BCBS is prohibiting providers from bringing those
appeals and leaving them without payment they are entitled to.
“With the rapid expansion of services requiring prior
authorization, the numerous continuing problems in BCBS’s and its vendors’
ability to process prior authorization requests and adjudicate claims
accurately or in a timely manner, Minnesota’s hospitals and health systems
are overwhelmed with the number of payment denials they are receiving from
BCBS,” the MHA letter states. “This volume of unpaid bills is making it
difficult if not impossible for hospitals to sort through and figure out
which BCBS policies are being applied to which claims, what grounds BCBS or
its vendors are alleging as the basis for the payment denials and which
payment denials can or cannot be appealed under these policies. In the
meantime, BCBS continues to enforce its timely filing and appeals deadlines
so hospitals and health systems are either not allowed to appeal a denial at
all or, in other situations, BCBS rejects the appeal because it was untimely
even though BCBS’s own failures are at the root of the delays.”
MHA is requesting investigations by the state because the
association and its members do not have all the information necessary to
determine conclusively which, if any, laws BCBS has violated. State
regulators have authority to conduct these types of investigations, gather
the evidence necessary to make those determinations and ensure state laws and
consumer protections are enforced.
The
Minnesota Hospital Association represents Minnesota’s hospitals and health
systems, which provide quality care for their patients and meet the needs of
their communities.
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