Providers Lose Appeal Over Insurer's MPPR Policy Change

Twitter icon
Facebook icon
LinkedIn icon
e-mail icon
Google icon

North Carolina advocates for health care providers have lost an appeal in a case centered on multiple procedure payment reductions for radiologists.

N.C. Hospital Association, the N.C. Medical Society and the North Carolina Chapter of the American College of Radiology (ACR) had filed the appeal in mid November after the N.C. Department of Insurance ruled that Chapel Hill-based Blue Cross and Blue Shield of North Carolina (BCBSNC) was within its rights to change reimbursement for the technical component of imaging services to pay 100% for the first image taken and 50% for all subsequent images. The change, according to a BCBSNC statement saved the insurer $30 million in 2013.

BCBSNC maintained that it did not need to renegotiate with providers when making the reimbursement policy change because it was correcting a situation where it was effectively being charged double for the same service. However the N.C. Hospital Association, the N.C. Medical Society and the North Carolina Chapter of the ACR argued that allowing insurers to change reimbursement policy without negotiating the change with providers set a dangerous precedent that could lead to more arbitrary reimbursement cuts between contract negotiation periods. What BCBSNC labeled a $30 million savings is of course a $30 million loss from the provider's perspective.

“We are disappointed in Judge Stephens’ decision and are in the process of fully evaluating his order. We want to be clear, the dispute was over the insurer changing the rules in the middle of the contract. The North Carolina Medical Society will continue to fight to ensure that when a health insurer makes a contractual promise – whether to a patient or a doctor – they keep their promise,” said Bob Seligson, CEO of the N.C. Medical Society in an article in The Business Journal of North Carolina’s Triad area.