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Regional Mettings

LOA Board Member meets with Blue Cross on Fixation Implant Reimbursement 
by Dr Jay Binder

The meeting began as response to a problem I was having with my OR schedule. For several years, I was able to take my arthroscopic cuff repairs, labrum repairs and ACL reconstructions to our ASC. This was great because I could take that case, as well as the TF cases, to the ASC and practice efficiently. When our ASC contracted with Blue Cross to go “in network”, it helped facilitate simple scopes and carpal tunnels, but hurt with the cases that required suture anchor implants or fixation implants and allografts.  My case load at the ASC dropped dramatically. My outpatient cases were then scattered at a number of institutions, including two traditional hospitals, and since most of my practice is outpatient knee and shoulder, I was sometimes going to three or four places on a surgery day to accommodate my patient’s needs. The additional problem was that the traditional hospitals were much harder to get on the schedule, gave us odd start times, and had turnover times that were double that of the ASC.

I am a member of the New Orleans area PAC (physician advisory committee) for LA BCBS. We meet quarterly to give BCBS feedback on problems and for them to tell us about changes they’ve made to their operation. Because of that I know Dawn Cantrell, V.P. of Network Administration, through those meetings.  I have talked about the implant issue at PAC for the past year or more, even with Mike Reitz, BCBSLA President and CEO, but it never seemed to resonate. When the East Jefferson negotiations heated up, I kept in communication with Dawn to give her my perspective as a provider and EJGH staff member. I also used those calls to suggest a meeting about the implant issue as it has to do with ASCs and physician-owned hospitals (POH).

I met with representatives from BCBSLA, an ASC administrator and a vendor to discuss the issues.  Attending were: Dawn Cantrell, BCBSLA V.P. of Network Administration; Tom Groves, Director, BCBSLA Provider Contracting and Service; Lisa Latino, BCBSLA Senior Network Development Rep; Dr Jay Binder; Larry Verges, Health Development Systems Director (management Co. for multiple ASCs); Lonnie Juneau, distributor rep (Cajun Medical) for Arthrex representing implant companies.

We discussed the ongoing EJGH negotiation and the desire by all of us to resolve it quickly. We found them more willing to talk about reimbursement for ASCs and POHs, especially in Jefferson Parish, because they now have an access problem for their subscribers, at least until the EJGH issue is resolved. Also, they seemed to appreciate the reasoned debate and data that we presented because we showed them why many of these cases had to be denied by the ASCs and POHs because they lost a lot of money.

Larry Verges presented data and invoices on three example ortho cases: RCR, ACL and a 2 level ACF. He showed the actual contracted reimbursement from BCBSLA for those procedure codes.  He demonstrated that the BCBSLA reimbursement didn’t even cover the invoice cost of implants and disposables on each of these cases.  His loss on every similar case would be about $740 for RCR, $ 1200 for ACL and $2800 for two level ACF. For that reason, even though the ASC is a BCBSLA provider, they will deny the case because they lose money every time. They will and do take break-even cases to get the doctors TF cases. If the projected break-even case turns out to be a loss, then that is acceptable because it is simply a fact of business and worth the risk to get the other cases.

When this in-network ASC refuses the case, we then take it to another facility, usually a traditional hospital or maybe a POH, who can take the case because their reimbursement schedule is greater and costs are more easily covered.  My hunch was that BC ended up paying “out-of network” traditional hospitals more than some “in-network” ASCs and POHs.  BC wasn’t sure about the actual pay-outs by facility and network status so they are now running the numbers to compare them so that they can have better data to formulate a solution. 

Their intention is to try to find a way to address the implant issue so that in-network providers don’t have to refuse the case, sending it unnecessarily to an out of network provider.  I also made a plea to protect the patient’s option and right to use out-of-network benefits because sometimes it is the only option based upon location or provider list. BCBSLA informed us that the fee schedule for facilities is constantly changing, sometimes to more, and that this may be available to an ASC or POH if they ask and the contract allows.

Finally, Dawn Cantrell reiterated a commitment to find a solution to the implant issue because it is a complaint and concern that they have been hearing from me and others around the state for a long time.  Please contact your Provider Relations or Facility Rep to share your experiences and problems with orthopedic implants as they are gathering data now in order to seek a workable solution.


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