Understanding Your New Blue Shield Contract

By Barbara Griswold, LMFT
(July 31, 2012)

Confusion was the order of the day this week when Blue Shield of California providers received new contracts in the mail. I interviewed a representative from the Blue Shield Provider Contracting Team, and here were his responses.

“Why are we getting new contracts?” BS gave these two reasons: 1) For simplification, to put all providers on the same contract, and 2) in response to the Affordable Care Act (aka healthcare reform), BS will be coming out with three new plans (BS Network A, B and C in on pages 21 and 24 of the contract). To compete with other insurers in this new insurance marketplace, these plans will be discounted to various degrees.

“What does this mean for me?” In addition to the “standard” BS plan you are now contracted with, you have the option to become a participating provider for some – or all – of these new plans. When you see members from the new plans, you would receive 10% – 30% less than your current reimbursement rate, depending on the plan (as outlined on Page 24). Or you can just continue to provide care only for clients on the “standard” network, for your current contracted rate. I repeat: According to Blue Shield, this contract does not represent a change in rates for clients who have the current, standard commercial BS PPO, EPO, or HMO plans.

“Why join the new plans and accept a discount on my already discounted rate?” Says BS: “Many formerly uninsured clients will be enrolling in one of the new plans. Also, a current client may switch over to one of the new plans, and you would no longer be a covered provider.” (However, the representative admitted, you could always join the client’s network at that time, which should not be any problem since you are already a BS provider.)

“Can I negotiate the reimbursement rates?” No, according to BS.

“I am not an eligible provider for Medicare and/or Healthy Families. Why are these listed plan options?” These options are for eligible providers only, and does not mean you were now eligible.

“How does Magellan figure into all this?” Magellan/HAI manages most (but not all) of the mental health for BS of CA members. For this reason, providers are being urged to join Magellan. But according to BS, this new contract does not affect your Magellan contract or compensation rates.

“What am I being asked to do?” ALL Providers are being asked to:

1. Read the contract, and sign and date it on page 20.
    
2. If you wish to participate in ALL of the new (and future) networks that you are eligible for, at the various compensation rates outlined on page 24, choose #1 on page 21.
    
3. If you wish to “opt out” of some or all of the new plans, choose #2 on page 21. REMEMBER: ONLY CHECK BOXES FOR THE PLANS IN WHICH YOU DO NOT WANT TO PARTICIPATE.
    
4. Fill out page 22 (and 23, if applicable).
    
5. Return all pages of the original signed agreement (pages 1 – 24) to Blue Shield. I recommend you keep and file a copy of the entire completed, signed agreement.

Still have questions? Call Provider Services at 800-258-3091 and choose the star sign (*). You actually should get a live person!

Sound like things are getting more complicated? You betcha. When a client says she has BS of CA, it has always been important to find out whether she is a “straight” BS client (handled directly by BS), or one handled by the BS Mental Health Administrator du jour (formerly USBH, now Magellan). But now if you choose to opt out of any plans, you will need to be sure at the start of therapy that you are a provider for the client’s particular BS network. Yet another reason to call up front. And we can expect other insurance plans to follow suit. (Stay tuned for updates…)

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Barbara Griswold, LMFT, is the author of Navigating the Insurance Maze: The Therapist’s Complete Guide to Working with Insurance – And Whether You Should. To purchase the book or other resources for therapists, click here. Contact Barbara at barbgris@aol.com to get answers to your insurance questions.

Copyright 2008-, Barbara Griswold, LMFT. No part may be reproduced without written permission of the author.