BCBS Texas Announces New Out-of-Network Reimbursement


September 1, 2010Allowable Amount Definition for Non-Contracting Providers to Change

Blue Cross and Blue Shield of Texas (BCBSTX) is migrating to a new out-of-network reimbursement approach. As groups renew with BCBSTX, the majority of out-of-network claims will be reimbursed based on a pre-determined percentage of Medicare rates.

Medicare provides a national standard recognized by all providers that is used to reimburse a significant portion of all medical claims in the United States. As a result, we expect the new methodology to increase transparency for providers and members through availability of information about Medicare standards. In a number of isolated instances, such as when a service is not priced by Medicare, a default pricing method will be used. This will be stated in the certificate of coverage. Our methodology has been submitted to and approved by state regulators in Texas.

We will begin meeting with our group customers to explain the new Medicare-based methodology. We anticipate that the overall impact of the new methodology will not be significant due to Health Care Service Corporation’s broad provider network, which results in more than 97 percent of all claims we process to be in-network.

To help avoid confusion for members during the transition to the new methodology, communication tools will be provided to the Full Service Units to address any concerns. Members also will be encouraged to continue to get estimates from out-of-network providers for the cost of services and to call us to help determine estimated allowable amount.

The migration will be upon group renewal beginning on Sept. 1, 2010, dependent upon successful testing.

 Editor’s Note: We like this approach and are encouraged that Blue Cross likes it too. Next step is to convert their PPO contracts in a similar fashion. With upcoming requirement under Obamacare, full PPO contract terms must be publicly disclosed, thus ending the PPO world as we know it today. This is a good thing (some change is good).