Unlock Health welcomes Jeffrey Gold as a guest author in our Managed Care blog series.

As a long-time healthcare advocacy lawyer, founding Bureau Chief of New York Attorney General’s Health Care Bureau, former Senior Vice President at the Healthcare Association of New York (HANYS)—and now, Special Counsel of its Managed Care and Insurance division—I’ve devoted a notable part of my career to taking on issues with Blue Cross Blue Shield’s BlueCard coverage and payment. For many years, the nation’s hospitals have provided immediate services and care to BlueCard holders who are covered by non-local Blues plans. Unfortunately, these invaluable services have not been paid timely, in full, or at all. The out-of-area plan coverage has been a bit of a black hole around eligibility, scope of coverage, authorization rules and payment. These payment delays, denials and barriers to care have long needed to be remedied.

That’s why the recent Blue Cross Blue Shield antitrust settlement comes as very welcome news for providers. While hospitals and healthcare systems across the U.S. continue to grapple with financial challenges and long-term instability, there’s no time like the present to improve the BlueCard system going forward and provide compensation for providers. The settlement, brought by the law firm Whatley Kallas on behalf of providers, awards a $2.8 billion cash payment that most providers who have treated the Blues’ patients will be entitled to receive a portion of. As the largest healthcare antitrust settlement in history, this is welcome news indeed, but the real power lies in the injunctive relief and BlueCard transformation dollars that address the future.

The settlement requires Blue Cross Blue Shield to invest hundreds of millions of dollars in system improvements that will address many of the prevalent issues providers face today. Here is just a sampling of these benefits.

• Transformation and accountability of the BlueCard system: BCBS will develop and implement a system-wide, cloud-based architecture that will enable the delivery of the System’s inter-plan claims data to resolve numerous issues with respect to submission, processing and payment of BlueCard claims, create real-time claims status messaging transparency on authorization and eligibility rules, and a meaningful escalation process.

• Significant changes to encourage more competition: The Blues have agreed to change their rules to allow contiguous area contracts to cover more members. These changes will make contiguous area contracts more valuable and workable as it will include more members.
• BlueCard prompt pay commitment: In addition to real prompt pay timeliness, there will also be requirements that the specific reason for denials or additional information the plan needs are fully disclosed.
• A full list and explanation of all the system transformation requirements of BCBS can be found here.

The amount of time and resources hospitals and providers must currently spend on navigating the Blues system and ensuring they receive rightful payment is high, with many employees dedicated to resolving billing and payment issues that this settlement will help resolve. Services are provided in real time; they should be paid in real time. The settlement payout will certainly benefit providers in the short term, but the providers who remain in the settlement will reap invaluable benefits for years to come.