Who if anyone benefits from the dismantling of the BlueCard® program?

In May of 2010, the BCBS Association notified Blue Plans of a change to the BlueCard® program that would require ancillary claims to be filed to their local plans for independent clinical lab, DME/HME and specialty pharmacy. For independent clinical labs the “local plan” was defined as the plan in whose service area the specimen was drawn as opposed to the service area in which the work was performed.
This policy change opens up a Pandora’s Box of problems for patients, laboratories, benefits administrators and the 39 Blue plans.
The provider’s home Blue Plan historically forwarded the claim through the BlueCard program to the member’s own Blue Plan to adjudicate the claim, and the member’s cost-sharing amount was calculated at the “in-network” rate based on the provider status of the performing laboratory and the plan to which the claim was submitted (i.e., the laboratory’s “home plan”).
With the elimination of the BlueCard program, if the specimen is not collected in the same plan region where the laboratory services are performed, the Blue Plan for the state where the analysis and clinical assessment services are performed will no longer forward the claim to the appropriate plan, requiring the performing laboratory to:

1. retain data on the location where the patient was drawn, even though there is no provision for a place of service for where the patient was drawn on the electronic claims form
2. submit a claim to the Blue Plan for that state, even though the testing laboratory may not be a contracted provider for that particular Blue Plan.

Since the electronic claim format has no provision for the disclosure of a location where the patient was drawn, the lab must create a manual system to determine the proper plan with which the claims should be filed and create a tracking mechanism outside of its normal automated routine for submitting claims. Many labs perform proprietary tests and services that are neither performed by or offer through other labs . None of the labs performing proprietary assays have contracts with each of the 39 independent Blue Plans. Therefore eventually as all plans abandon the BlueCard program, BCBS enrollees’ access to needed testing procedures will be jeopardized. Patients may not realize that laboratory testing may be performed in another state and stand to be confused and frustrated when their claims are denied or reimbursed at an “out of network” rate.

Each independent clinical lab and each Blue Plan will bear the cost of negotiating and maintaining separate agreements with each other, with labs either not being reimbursed at all or being reimbursed at a lower non-participating rate if they are unable to contract with a certain plan. Complicating matters is the fact that many of the Blue plans are not contracting with new, out of state providers, making it impossible for labs to get reimbursed for tests where specimens were collected in those jurisdictions.
The new system turns a straightforward process into an unnecessarily complicated and expensive one. The Blues, considered one of the largest health benefits organizations, collectively provide coverage for more than 98 million enrollees. This change to the BlueCard® program effectively transforms these 39 Blue plans into small regional payers that will not be able to reasonably service the needs of large multi-region employers. The ultimate impact of this policy shift will be that employers, and not just lab employers, may choose to contract their benefit programs with national providers such as UHC, Aetna or Cigna.

Given the impact of this decision on patients, laboratories, employer groups, benefits administrators and the Blue Plans themselves it is difficult to see who if anyone benefits from the dismantling of the BlueCard® program. In fact, to date half the Blues have not implemented the change because they are unsure of the impact on patients and administrative fall out for claims processing. Is the BCBS Association, who insists this is nothing more than a simple contracting issue, trying to eliminate out of network providers to reduce costs; or are the larger labs with exclusive contracts forcing the Blues to enforce their exclusivity arrangements that disadvantage regional labs and prohibit them from competing in the market place? Is the BCBS Association trying to prepare for the new healthcare environment under the Affordability Act by limiting providers to only those willing to perform services at the lowest cost by forcing providers unable to obtain regional contracts into their GPO style national partnership agreements for the Blues system? Is Wellpoint, who now controls 14 states with 35 MM BC lives, influencing change within the Blues to their best interest?

XiFin urges BCBSA to collaborate with stakeholders on all sides of the issue to rethink this program change, both in terms of mitigating the erosion of patient access to vital laboratory testing and services, and in terms of the increased cost and administrative burden created by the policy change. A more concerted and direct effort should be made by providers to educate employers and beneficiaries that access to needed services will be lost, while out of pocket costs will make these plans cost prohibitive.