Watching and Waiting: BCBSMA Privileging Changes Keep Industry on High Alert
By Sarah Spataro
Recap
In our spring issue, VEIN broke a story about imminent changes to RFA/EVLT privileging requirements in the Blue Cross/Blue Shield of Massachusetts physicians network. Effective April 15th, all physicians wishing to be reimbursed for these procedures have to be vascular surgeons, interventional radiologists, or general surgeons prior to the establishment of vascular boards.
These changes effectively exclude a large percentage of vein specialists who have been expertly treating superficial venous disease for years, but who do not fall within the BCBSMA guidelines.
In addition, all sites of treatment have to be accredited by ICAVL or ACR. But BCBSMA ignored the fact that ICAVL and ACR accredits diagnostic labs, not therapeutic. In a letter to BCBS, the Society for Vascular Ultrasound (SVU) writes:
“There exists, however, an incompatibility with the policy as written: many venous ablations are performed in settings outside the non-invasive vascular laboratory. The referenced accrediting bodies do not offer therapeutic ultrasound facility accreditation; therefore there can never be compliance with the BCBS policy in these settings.”
BCBS maintained the party line that this is a “quality-driven initiative,” and never so much as alluded to a sharp increase in claims that must have coincided, over the last five years, with an explosion of improved ablative technology. But most members of the venous community cried foul, viewing this as a multi-level assault on patient’s access to care, and physician’s access to reimbursement. It is a widely—if not unanimously— held belief that the only beneficiaries of this policy shift will be the insurance companies themselves. There is also speculation, and trepidation, that Blue Cross will set the precedent for other organizations to follow suit.
A task force, staffed by physicians and industry leaders nationwide, was assembled to address the issue with BCBS.
What’s Happening Now?
As summer settles in all over the country, there is a quiet yet palpable tension around the issue, yet little progress has been made to change or modify the new policy. This is not for lack of effort within the industry; physicians have acted individually and societies, such as the above-referenced SVU, have written respectful but straightforward letters. It is the stalwart resolve of BCBS that has things at a standstill.
In a response letter to the SVU, Jan Cook, the BCBS medical director supporting the initiative, wrote:
"The [RFA/EVLT] privileging program is a quality initiative designed to evaluate the professional training and facility standards of providers who perform these services for our members…. We already have a large number of providers who meet this standard. We are currently in the process of evaluating the need to make exceptions to our criteria to ensure members have appropriate access to these services.”
Whether this is a polite brush-off or an earnest expression of reconsideration remains to be seen. Only time will tell. We can only hope that the more they hear from concerned physicians, societies and industry members, the more diligently they’ll attempt to reach a fair compromise vis-à-vis those unjustly affected by the change.
Speaking of whom, VEIN caught up briefly with Doctors Elizabeth Foley and Judith Hondo, the Boston vein specialists who brought this issue to the attention of the ACP in December. They estimated that 40% of their patients are BCBS members, and that this change could have a deep impact on them. As yet they have not seen a significant decline in business. However, they were quick to point out that summer is always their slow season; people are reluctant to wear the compression hosiery required for recovery during the short New England summers, and office hours are seasonally shorter as well.
The doctors did receive a visit from a BCBS representative, to whom they explained their concerns and verified their outstanding credentials. He said he had a better understanding of their situation and that he would take their case back for review. But things at BCBS are slow to change, he said…. And so the doctors remain in a holding pattern, hoping BCBS will change with (or before) the seasons do.
Finally, a brief follow-up with Dr. Nick Morrison, President of the ACP and an outspoken critic of the BCBS move, confirmed that there are at least a half-dozen other organizations in various states considering similar changes in their RFA/EVLT policies. Asked if he believed that continued pressure on BCBS would stay their hands, he replied, “We have no way of knowing. We would hope so, we should continue in our efforts to reverse or revise BCBS policy. But what the other organizations will do, and when, we really have no way of knowing.”
In sum, there is still a tremendous amount of energy surrounding this situation. The productive energy, the letter writing, phone calls, and visits to BCBS representatives have kept a persistent pressure on BCBS. Then there is the other energy, the anxious buzz that surrounds rumors and speculation of an industry on the cusp of a forced restructuring. One thing is certain: neither type of energy is dissipating among the venous professionals who are passionate about what they do and why they do it.
We at VEIN will also continue to wait and watch and listen, bringing you updates on this issue as it evolves.