The centerpiece of the Settlement Agreement is Section 7, which required BCBSNC to change many of its basic business practices with regard to physicians. For example, Section 7 includes restrictions on when BCBSNC could seek recoupments, notice and timing requirements for contractual changes, disclosure and notice of claims payment and coding edit practices, and so on. You can review the Settlement and more about the original legal disputes at http://www.hmosettlements.com/.
In the final weeks of the Agreement, NCMS engaged BlueCross in a conversation about its intentions to commit to permanently implementing many of the good practices embodied in the Agreement. In response, BCBSNC has agreed to permanently adopt several key components, including:
- Disclosure of complete fee information via BCBSNC’s secure provider website.
- Reduced prior review and precertification requirements. BCBSNC has committed to work with its self funded clients to limit customization of the prior review list.
- Convene regular meetings between BCBSNC medical directors and physicians to discuss issues facing members of the BCBSNC provider network. The Joint Advisory Group served this purpose under the Settlement, but was recently merged into a modified Physicians Advisory Group.
- Abide by the provisions pertaining to prompt physician credentialing.
- Follow the coding rules under Section 7.20, which discusses the use of modifiers and bundling, and continue public disclosure of significant edits.
Several disputes between physicians concerning BCBSNC’s compliance with Settlement provisions are pending and will continue beyond the expiration of the Agreement. However, physicians and practices will no longer be able to file new disputes against BCBSNC for alleged violations of the Agreement.