Blue Cross Ratings 'Deceptive and Invalid'

Blue Cross and Blue Shield of Texas' BlueChoice Solutions (BCS) physician-rating system does not use an accurate or independently validated method to determine a physician's risk-adjusted cost. That, combined with other problems with the program, "renders the method deceptive and invalid for credentialing and related performance assessment purposes at both individual and group physician performance levels as well," a Texas Medical Association ad hoc committee concluded.

Chaired by San Antonio emergency physician Robert W. Kottman, MD, the Ad Hoc Committee on BlueChoice Solutions/Risk Adjusted Cost Index (RACI) conducted a detailed examination of BCS. The committee looked at issues such as clinical attribution, accurate comparisons to peers, and expense of admitting/treating facilities

The committee's report [ PDF ] to the TMA Board of Trustees and Council on Socioeconomics made four observations and recommendations:

  1. The current method for "actual cost" assignment BCS uses to determine a physician's RACI is seriously flawed, is not scientifically validated, and should not be used as a relative measure of "affordability." Costs are inaccurately and/or unfairly attributed to physicians caring for BCS patients. "Examples would be imaging and/or lab tests ordered by other physicians, or a patient's decision to pursue an emergency department visit in lieu of scheduling a physician office/medical home visit. When more than one physician is involved in the care of a complicated patient with multiple co-morbidities, it often becomes virtually impossible to appropriately assign the costs of care to a single physician. The BCS RACI, however, does exactly that."
  2. Blue Cross should immediately address and resolve claims coding and processing system problems. There is a serious question about Blue Cross's capacity to receive electronic or paper submissions with all of the coding information necessary to fairly and completely process BCS claims. The issue deserves Blue Cross's prompt attention since an important root cause of the problems with the BCS claims database is inaccurate and/or incomplete data generated from the Blue Cross claims coding and processing systems. These capacity concerns threaten the integrity of transactions in the network and the viability of the network itself. 
  3. Important information related to covered BCS benefits and related patient service costs outside physician offices is generally not available nor disclosed to participating and/or billing physicians. All relevant cost of service attribution and covered benefit information affecting BCS network physicians' service and referral decisions for patients/enrollees should be fully transparent, available, and disclosed to physicians and patients in all applicable, covered settings of care. Blue Cross should "substantially improve and make transparent all due process options…"
  4. Clear and unambiguous information that describes the process for appealing their rankings is not easily available to physicians, their offices, and patients. In addition, the company's local provider service representatives sometimes give BCS physicians or their staff conflicting, incomplete, or inaccurate information about how to appeal, and the distinctions between requesting disputed data on RACI scores and actually filing a formal appeal. Blue Cross should substantially improve and make transparent all due process options under the Health Care Quality Improvement Act.

"I think the report speaks for itself, and I wanted to let you know that TMA fully stands behind and supports the recommendations in the report," TMA President Josie R. Williams, MD, said in a letter forwarding the report to Blue Cross Chief Executive Officer Darren Rodgers.

"The report is well conceived and researched, and also reflects the many reports we've received from our members about their experience with the BlueChoice Solutions risk adjusted cost index. As the report notes, it is our strong conclusion that the RACI methodology is sufficiently flawed to render it invalid for use in credentialing and recredentialing BlueChoice Solutions network physicians," she wrote. 

"We sincerely hope Blue Cross Blue Shield of Texas will review the findings, and take appropriate action to discontinue the use of the BlueChoice Solutions RACI in that plan's network credentialing."

Physicians who don't agree with the rating Blue Cross gives them can log on to the TMA Web site for an explanation of the rating system, an easy way to log your complaint, and information on what you can do if you don't like your rating.

The July issue of Texas Medicine will have more information on the Blue Cross rating system and TMA's response to it.


Action , May 16, 2008

Last Updated On

April 01, 2011