Restrictions by Regence BlueCross BlueShield Irritate Practitioners

A pre-certification process was instituted Nov. 1 placing barriers in the way for people seeking care from alternative medical providers such as acupuncturists.
Until recently Regence BlueCross BlueShield had a glowing reputation among alternative care providers, and there were very few restrictions on what they could do for their patients.
 
Then CareCore National, an evidence-based healthcare solutions company, entered the picture after signing a contract with Regence. Starting Nov. 1, the prior approval process came into play affecting acupuncturists, chiropractors, massage therapists, naturopaths, physical therapists and speech pathologists who are feeling the pain. Rather than taking care of their patients on an “as needed basis,” CareCore now determines the number and frequency of any visits involving physical medical care.   
“How could Regence go from being the best insurance company to work with, being very fair with patients to the most restricted; I’m unclear why they’re taking that tack?” questioned Beth Howlett, president of the Oregon Association of Acupuncture and Oriental Medicine. 
 
In the hope of convincing Regence to back off, Howlett and her colleagues asked for a meeting with John Prassas, vice president of network management – but haven’t heard a response and are concerned other insurers might follow Regence’s lead.  
 
“I believe there’s still room for dialogue,” Howlett said. “The safety profile of acupuncturists is excellent; there has to be a better way to accomplish this. We’re hoping to have a dialogue with Regence on the annual benefit caps and create utilization guidelines not limited to the top codes for physical medicine.”
Currently there are 1,372 licensed acupuncturists in Oregon, with the majority – 969 – practicing in the Portland area. 
 
Laura Cali, Oregon’s insurance commissioner, has also been thrust into the picture, and is taking the issue under advisement after receiving numerous letters protesting Regence’s decision from consumer advocates.
 
“There are various options,” Cali told The Lund Report. “But at this point I’m not finished with my analysis.”
 
For the time being, Regence’s decision is hitting acupuncturists hard, and they need prior approval before treating their patients for physical conditions such as insomnia, anxiety and menstrual pain. 
 
“The new pre-authorization guidelines blatantly ignore recent research that supports the cost-effectiveness and efficacy of integrative medicine methods,” Howlett told Regence’s Prassas. “Regence is deliberately ignoring recent pertinent research which demonstrates that the use of integrative medicine by patients, on the whole, results in lower health insurance expenditures than those who do not utilize integrative medicine.” 
 
Furthermore, she wrote, these guidelines will create financial hardship for Regence members, undermine the scope of practice of medical practitioners and ultimately will have a negative impact on the delivery of patient care. 
 
Jeff Clark, a naturopath physician in Portland, wondered if something else was actually going on behind the scenes.    
 
“It just doesn’t make sense,” says Clark, who recently joined the board of the Oregon Association of Naturopathic Physicians. “Why is there a push for this now? Have they already cost contained every high dollar specialty service and is this the last of the low-hanging fruit? Seems unlikely. ”
 
As a comparison, he said, it takes 50 acupuncture treatments at $70 each, to match the cost of just one colonoscopy procedure at $3,500. 
 
“If this is truly about reining in healthcare costs, it certainly appears from the outside that there are bigger fish to fry first,” he added. 
 
By selecting a small subset from a very large book of CPT codes (used for reimbursement) for intensive scrutiny and pre-authorization management, not only will patients have a more difficult time accessing such services but there’s going to be considerable more insurance paperwork on practitioners, Clark said.
 
“It will also affect the very few medical doctors that practice acupuncture, osteopathic physicians that still provide the osteopathic manipulations their branch of medicine was founded on, and the subset of naturopathic doctors that also utilize manipulation therapies in their regular practice,” he said. 
 
Regence Responds to Critics 
 
Defending Regence’s decision, spokesman Jared Ishkanian insisted the new policy will help control costs and improve quality of care.
 
“Prior authorization does not mean no,” he told The Lund Report in a written response. “What it means is we are asking the provider, ‘are you sure that this treatment is medically necessary, and are there any other options worth considering?’ Currently, the total cost of treatment is not always visible to the member, which can result in unnecessary treatment and wasteful spending. This program is an effective way for us to bring everyone into the conversation to help ensure that a procedure is medically necessary and financially responsible. 
 
“It is important to note that member benefits remain unchanged, and for group business, these changes only apply to full insured groups, not to self-funded groups. 
 
“Regence is always willing to work with providers and our members to improve our system and come up with a system that works best for all involved. 
 
“Regence is committed to making sure our members get the right care at the right time, and that we’re being good stewards of their health care dollars. Prior authorization programs help ensure that members receive safe, necessary and high-value treatment. With 30 percent of all current health care spending attributed to waste, prior authorization is a proven and effective method of creating a more economically sustainable system. 
 
“The program focuses on providers that have a high degree of variability that fall outside the normal pattern of treatment, and for services where treatment is unproven or can possibly result in patient harm. Providers who fall outside of this minority will be minimally impacted by the program.”
 
Diane can be reached at [email protected].
 
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Comments

Get the fine print of plans that are sold on the exchange. Unfortunately, that often takes more than just looking at the materials at Cover Oregon... Pre-authorization is a gotcha' of many of the plans--especially the cheapest plans.