Our Vision:


© Copyright San Juan Independent Practice Association, 2018. All Rights Reserved.


Recent News: UPDATED 10/11/2018
  1. To ensure that a heath care delivery system is in place, which provides available, accessible and adequate numbers of facilities, locations, and personnel for the provision of health care services.
  2. To ensure that a health plan members are provided covered services without regard to race, color, creed, sex, religion, age, national origin, ancestry, marital status, sexual preference or physical or mental handicap.
  3. To ensure that the SJIPA has in place the organizational and administrative systems capable of messaging medical services contracts between providers and third party vendors
  4. To ensure that the quality of care to all patients continues at the highest level of  care possible.  
  5. Provide support for community health education and wellness.


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The San Juan IPA was founded in 1986 by a group of 21 community physicians to partner with

insurance companies with the goal of improving the quality of care to patients while simultaneously

decreasing the cost of care to those payers. Originally formed with a “Quality Assurance Committee”,

the San Juan IPA has grown to over 450 members representing 39 specialties and sub-specialties

in 70+ offices across New Mexico, a HEDIS quality review function, a Credentialing Committee,

and a care management committee component.


As an NCQA-accredited organization, San Juan IPA’s core services of contracting and

credentialing are complemented by an array of expanding resources for the physician office,

helping keep practice costs low and quality of care high.  We continually look for ways to

promote new quality initiatives both within and outside the practice walls for patients and employers.


To all San Juan IPA members:   Centennial Care 2.0 Plans


**SAN JUAN IPA MEMBER SPECIAL ALERT**


San Juan IPA has received several questions about the Centennial Care 2.0 plans and if we will be contracting with the three MCOs (BCBSNM, Presbyterian, and Western Sky/Centene) for these lines of business.  The IPA has signed a Letter of Agreement with Centene and we have every intention of signing a full agreement with them by the end of the year.  We have also sent back the Amendment to Presbyterian for final review, and we believe we will be signing that imminently.  Unfortunately, BCBSNM is a different story.


To give some historical background and to provide perspective, the last contract round between San Juan IPA and BCBSNM became contentious over a certain section in the contract that stated that BCBSNM could change a provider’s reimbursement with 30 days’ notice, and the only recourse the provider had was to terminate the contract.  This language is in every other direct provider contract across the state, and San Juan IPA did not see how that was fair to the provider.  Our position was, and still is, that once reimbursement has been agreed to then the only way either party can change it is by opening renegotiations, but not by unilateral decree.  We stood by that position with our member’s support until BCBSNM removed the language from the contract.


Things have not improved since that time.  BCBSNM has since not allowed San Juan IPA members- both those who have been with the IPA for a long period or our new members- to join the BCBSNM contract through the IPA, calling it a “business decision” but not giving any other rationale.  Providers who have contracted directly have had that (what I consider to be) predatory language in their contracts, along with several other items that run counter to the New Mexico Administrative Code and/or CMS.  When providers have asked to remove that language BCBSNM has either told them that they won’t (in the case of the reimbursement language) or have been less than straightforward with providers, telling them in writing that the BCBSNM computer system can’t accommodate the request, that the language is standard and can’t be changed, or some other less than accurate or forthright excuse.  We know these claims to be false because a) the IPA contract is not written that way, and b) this is the law.  Saying that you can’t configure a contract to conform with the law is rather dubious.


San Juan IPA challenged BCBSNM’s “business decision” through the OSI.  While that process is still ongoing, I am not confident that we will be successful in getting the OSI to assist us.  According to the OSI, they do not get involved in “contractual matters” and consider the above under that heading.  We disagree, and our position is that if “business matters” violate the law then the OSI should be involved.  Again this discussion is ongoing, but the IPA is taking the imputed advice from the OSI:  If this is a contractual matter, then it should be resolved within the contract.  This is where Centennial Care 2.0 comes into view.


BCBSNM requested that San Juan IPA sign the Centennial Care 2.0 Amendment.  San Juan IPA responded, noting that most of the Amendment followed the state contract but requested this language be inserted:


i.A.ii.  Any Willing Provider means any IPA credentialed provider who has requested participation with BCBSNM under the IPA network contract.


iii.C.i.  Provider Selection.  Corporation will comply with the provider selection requirements specified in 42 CFR Section 438.12 and 438.214 and maintain policies and procedures that reflect these requirements.

 

a. Corporation shall not deny Any Willing Provider participation solely due to Provider being a member of IPA.

b. Corporation has the right to seek to directly contract with any IPA Provider; however, upon written confirmation that IPA Provider requests to only contract with Corporation under the Agreement, Corporation shall not deny Any Willing Provider participation.


As you can see, San Juan IPA is advocating for our providers by giving you a choice in how you contract with BCBSNM.  Since BCBSNM is not giving any reasons to providers to not allow them to contract under the IPA, we’re stating that they can’t deny solely on that basis (part a, above).  We are also making sure that we are not violating the law (specifically anti-trust) by stating that BCBSNM has the right to directly contract, but the provider has the equal right to contract through the IPA (part b, above). Because I fully expected BCBSNM to respond by stating that the CC 2.0 language had been approved by the state, I told the representative that I was offering to place this language in the base contract instead.  Unsurprisingly BCBSNM denied my language, stating in part:


“Disappointingly, SJIPA instead proposed a major unrelated concession from BCBSNM.  Specifically, SJIPA wants BCBSNM to give up a legal right to contract directly with providers outside of SJIPA.  BCBSNM will not compromise this right. “ [emphasis added]


As you can see, BCBSNM is being less than forthright in a literally black and white fashion.  San Juan IPA did not in fact ask BCBSNM to give up that right; indeed we very specifically stated that the payer has that right but you, the provider, has the ultimate right to contract with the payer as you see best for your facility.  That is really what BCBSNM doesn’t want to happen.


San Juan IPA will respond to BCBSNM today denying the allegation they have put forth and additionally stating that we will continue to advocate for our members.  However, San Juan IPA will not sign the BCBSNM Centennial Care 2.0 Amendment until BCBSNM recognizes the provider’s right to contract in a fair manner that fits the provider’s business and operational needs.  We understand that BCBSNM will likely be reaching out to our members to get them to sign directly with them, and again, we advocate for your choice in the matter.  We also believe that BCBSNM will be somewhat disingenuous in telling providers that the IPA is refusing to contract, which is why I’m giving you all the facts now.  We hope that our members recognize that, just like we did with the predatory contract language regarding reimbursement, the IPA continues to advocate for fair treatment for all of our members and will support us in this effort.


As always, if you have any questions regarding our position please do not hesitate to contact me.  Thank you.


Casey Crotty

Chief Executive Officer

San Juan IPA and Affiliates






All San Juan IPA Members, Office Administrators & Managers Only:  Annual Membership Meeting

The San Juan IPA will be hosting our 2018 Annual Membership Meeting on Friday October 26, 2018 at 6:00 pm at the Buffalo Thunder Resort and Casino, Santa Fe, NM.  The meeting is for all San Juan IPA members and office managers/administrators only.  If you plan to attend please RSVP Heather DeLaBarcena at heatherd@sanjuanipa.com or call 505-564-7980


CME’s are available for all practitioner attendees & a 5% credit for any and live streaming attendees for 1 yr for MedPro insureds

*If your already receiving the 5% discount, you will not receive an additional 5% credit.


Meeting the Challenge:

Managing Difficult and Noncompliant Patients


-Presenters-


Senior Patient Safety & Risk Consultant, MedPro

Group and


Remo E. Gay & Associates, P.C.


In addition to a CME presentation from MedPro, we have also scored a presentation from Shawn Mathis, an attorney who is drafting the bill for legislation regarding prior authorizations!  I know that prior auths are a major sore spot for provider offices (and the hospital too) she’ll come and talk with you about the bill and what it could mean for healthcare in New Mexico.  She will be doing a 45 minute presentation with a 15 minute Q&A session afterwards