Economists find Blue Cross Blue Shield antitrust settlement means more than $17.3 billion of value for providers

We recently learned that healthcare economist experts working on the Blue Cross Blue Shield antitrust case for the past decade have calculated a value for certain aspects of the the settlement’s injunctive relief in excess of $17.3 billion over the first ten years of its implementation. The experts have found that the administrative cost savings to Providers from just these aspects of the relief had an average value of $7.55 for each BlueCard claim.

What is injunctive relief?

In simple terms, injunctive relief court order that require a party to do something or stop doing something. In this case, it requires Blue Cross Blue Shield to provide the relief set forth in the settlement, which improves their BlueCard Program and addresses prevalent issues providers have faced for decades.

The announcement relays that “in addition to a $2.8 billion monetary payment, the significant benefits of the settlement’s injunctive relief include specific commitments relating to transparency, efficiency, and Blue Plan accountability that will directly benefit providers and the patients they serve.”

This article cuts through the legal jargon to summarize exactly how the the injunctive relief will tangibly impact providers on a day-to-day basis – starting with the new prompt pay requirements.

The prompt pay injunctive relief for providers in the settlement is enormously important – what does it do?

• At last, there will be a time clock for Blue Card claims. Most states have prompt pay laws for health care claims that require adjudication and payment of  claims within 30 days (depending on the state) for electronically submitted claims and 45 days (depending on the state) for non-electronically submitted claims. But BlueCard claims have always been exempt because the state where the provider delivered services had no jurisdiction over the out of state claim. This meant hospitals and doctors could only wring their hands and wait for payment. No longer. For five years after the settlement becomes effective, fully insured commercial BlueCard claims will be on a similar clock. This alone makes the settlement solid gold.
• Non- compliance results in interest being paid at the rate of 8%. This will compensate providers for delays, and it should reduce providers’ concern that the out of area plan is making money on the float. More solid gold.
• No more mystery denials. The BlueCard out of area plan has to provide the medical basis for a denial. No more having to guess the reason. How hard has it been for hospitals to have to write appeals and guess the reason? Gold.
• No more mystery pended claims for lack of missing information. No more having to guess what documentation the BlueCard plan needs. Now the plan has to tell the provider precisely what is needed. Gold.
• If there is any defect or error in a BlueCard Claim that prevents the claim from entering the Blue Plan’s adjudication system, the Blue Plan shall notify the Participating Provider within thirty (30) calendar days of receiving the claim. And each Blue Plan will designate at least one senior-level “BlueCard Executive” who will be accountable for issues regarding BlueCard Claim payments issues. You get it…gold.

These are enormous advances in the universe of BlueCard transactions. Opt out of the settlement and lose these prompt pay reforms? No thanks.

Jeff Gold is an attorney with more than 30 years of industry expertise. The opinions expressed are solely his own and do not express the views or opinions of the Healthcare Association of New York State.