May 02, 2014
Area(s) of Interest: Payor Issues and Reimbursement
Physicians who do not want to participate in Anthem Blue Cross's individual/exchange network have until June 30, 2014, to opt out.
Anthem Blue Cross recently notified over 11,000 practices that are currently participating in its individual/exchange network of a contract addendum that will become effective July 1, 2014. The amendment only applies to physicians who are currently participating in the Anthem Blue Cross individual/exchange network.
According to the notice, which was mailed on March 31, the addendum contains new regulatory requirements. While many provisions are requirements of Covered California, the California Medical Association (CMA) has concerns with certain provisions that appear to be beyond the scope of regulatory requirements.
One provision of significant concern is language in section 12 that removes a participating physician’s ability to opt out of the individual/exchange product without affecting the underlying Prudent Buyer contract, as is allowed currently. Effective July 1, the only option for physicians who wish to opt out of the individual/exchange product is to terminate the underlying Prudent Buyer PPO agreement.
Physicians do have the right to opt out of the Anthem exchange product without affecting the underlying Prudent Buyer PPO contract if Anthem receives notice before the effective date of the addendum, July 1, 2014. The notice must be received by Anthem by June 30.
If you do not wish to participate in the individual/exchange product, you can opt out by providing 90 days written notice, which should be sent via certified mail with return receipt, to:
Anthem Blue Cross Prudent Buyer Plan Contract Processing
Attn: Individual/Exchange Contract Processing
Mail Station 8A
P.O. Box 4330
Woodland Hills, CA, 91365-4330
Please cc CMA on any opt-out notices submitted to Anthem at California Medical Association, Center for Economic Services, 1201 J Street, STE 200, Sacramento, CA 95814.
For more information on the Anthem exchange addendum, click here.
Physicians are reminded that even if they opt out, their PPO patients may still have some out of network benefits. Patients with EPO products will likely not have any out of network benefits However, be aware that Blue Cross and Blue Shield refuse to honor assignment of benefits and will send any out of network payments to the patient. Therefore, it is recommended that physicians collect payment at the time of service for Blue Cross or Blue Shield patients they see out of network.
Contact: CMA reimbursement helpline, (888) 401-5911 or firstname.lastname@example.org.