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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-
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-
“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.
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 firstname.lastname@example.org or call 505-
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
Senior Patient Safety & Risk Consultant, MedPro
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