July 1995 Bulletin

Orthopaedists persuade 'Blue' to drop X-ray policy

The Washington Orthopaedic Society has persuaded Blue Cross of the National Capital Area to rescind its policy of regarding reimbursement to physicians for the professional component of X-rays taken in private offices on the day when clinical services, such as an office visit, are performed.

The only exception to the policy, which was adopted Jan. 3, was for radiologists whom the insurer contends provide no clinical service other than reading an X-ray. The rationale offered by Blue Cross was that non-radiologists are already paid for reading an X-ray as part of their clinical consultation.

The Washington Orthopaedic Society, headed by George Branche, MD, decided to fight the change in the policy. The society said that the first step was to hire an experienced antitrust lawyer, believing that is a "crucial step in any attempt to contest arbitrary unilateral action by insurance companies. The government is sensitive to any action by physicians which includes any hint of a threat on an organized basis, and the antitrust consequences of any appearance of organized action are potentially huge."

A minor injury to a high-ranking Blue Cross official stimulated a dialogue which eventually relieved a stalemate. Presenting at the office of an orthopaedic surgeon, the official was told that he probably did not have a fracture. He was then told that under the new Blue Cross guidelines he should return to the office the next day to obtain an X-ray, but he could not see the physician on the day the X-ray was obtained. The official was told he should make a third appointment to come back to discuss the results of the X-ray and the planned treatment. When he asked why other patients could have an X-ray, he was told that his insurer would not pay a reasonable fee for the X-ray taken on the same day as the visit. After demonstrating how the policy would work for a patient, the doctor eventually did take the X-ray on the same day as the visit.

Later, Blue Cross contacted the orthopaedic surgeon and agreed to a meeting to discuss the reimbursement policy. Dr. Branche, several members of the Washington Orthopaedic Society and the antitrust counsel met with Blue Cross. The orthopaedists pointed out both the inefficiency and the lack of cost-effectiveness of the X-ray payment policy. It would require every patient to make three trips for treatment of a single problem and Blue Cross would have to pay for two visits for every patient instead of one.

They also pointed out that the level of patient dissatisfaction in the community is extremely high, and that physicians have become the apologists for an increasingly inconvenient and, paradoxically, more expensive strategies of managed care insurers.

Later, Blue Cross called Dr. Branche and agreed to rescind the policy. The orthopaedic society has requested that the restoration of reimbursements be made retroactively to Jan. 1, to avoid penalizing those physicians who continued to provide appropriate services to patients despite the failure of reimbursement.

The Academy, the local medical society, and the AMA assisted the orthopaedic society in this effort. In a statement, the orthopaedic society said, "Perhaps, the most important lesson and the most potent force in convincing Blue Cross to rescind its policy, was the realization that it is the physician who allows managed care policies to succeed. By being the apologists for the insurance company, attempting to provide services to the patient which the insurer tries to discourage, the physician allows the insurance carrier to reap greater profit, inconvenience the patient, cut reimbursement, and gain more power."

The threat of 'playing by the rules' explaining to patients that certain services are uncovered or must be obtained elsewhere, and actually having the patient live by those rules, often puts the situation in perspective.

"If we encourage our patients to go back to their employers and insurance companies, and to demand that some of the onerous policies of managed care should be rejected, reconsidered, and changed, we will return more control of medicine to the patient, and the physician, where it belongs."

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