Doctors unhappy with Blue Shield reimbursement


Break a leg? Have Blue Shield? Don’t worry, you’re covered for emergency room care at Tahoe Forest Hospital. You are not, however, necessarily covered for conditions requiring you to see a family practice physician, a gynecologist, obstetrician or a general or orthopedic surgeon among others.

Although the hospital still accepts Blue Shield, many individual physicians in the community have either already dropped Blue Shield or they’re thinking about it.

“The hospital has no plans to drop Blue Shield,” said Larry Long, the hospital administrator. “More and more physicians are dropping Blue Shield because of the very poor level of reimbursement they pay.”

According to Long, Blue Shield pays 95 percent of the hospital’s charges, but they pay as low as 40 percent in reimbursement fees for individual physicians.

“It’s an intolerably low level of reimbursement,” Long said.

Because TFH is still under contract with Blue Shield, all hospital-based physicians are also required to accept Blue Shield from patients. Hospital-based physicians, however, up until January, included emergency room doctors and the staff radiologists; all other physicians, surgeons and specialists have the freedom to choose what plans they wish to accept or discontinue.

Emergency physicians

According to Long, in January, Blue Shield dropped emergency room physicians from the hospital contract, leaving them in the category of private physician to negotiate with whomever they choose, regardless of the hospital contract.

“(Blue Shield) told them you’re either out on your own, or you can contract with us at the standard physician rate,” Long said.

In keeping compatible with the hospital insurance policies, the emergency room physicians contracted again with Blue Shield for a short period of time until different contract terms can be worked out, Long said.

“For the time being, they’re (emergency room doctors) included and we’re going to do everything we can to keep that in place, but ultimately, it’s the physician’s choice,” he said.

And some physicians, including four orthopedic surgeons with North Tahoe Orthopedics in Truckee, discontinued their contract with Blue Shield on Feb. 4. The four physicians, William Krissoff, James Fischer, Deane Stites and John Foley didn’t return repeated calls this week, but they did issue a letter to their Blue Shield patients explaining the change in their insurance policies.

According to the letter, “current Blue Shield reimbursements are 35 to 40 percent of standard charges. As the rate of reimbursement has fallen well below our costs to continue to provide quality patient care, we can no longer afford to be part of the Blue Shield Contracted Provider Network.”

Other doctors besides the orthopedic surgeons are also considering terminating their Blue Shield contracts.

“I have not dropped it, but I sure am thinking about it,” said Chris Richards, a gynecologist and obstetrician in Truckee. “It doesn’t pay me. They’ve found a point below which a doctor will work for.”

Blue Shield representatives declined to comment by press time.

Regardless of what individual doctors do with their Blue Shield contracts, TFH is “trying to come up with a half a dozen or so (health) plans to make available to the community,” Long said. “We’re looking for new alternatives. We want people to be able to pick from a variety of plans.”

According to Long, some of the plans the hospital is considering are its own licensed Preferred Provider Organization and a Health Maintenance Organization.

“Expect our own PPO in about six months to a year, and the HMO in a year plus,” Long said.

According to Richards, Blue Shield is a popular plan for Tahoe residents because it’s relatively cheap, but it’s not the only affordable health plan available.

“What I’d like to see people do is go back to their brokers and say, ‘that didn’t work (Blue Shield) now what do you have for me?'”

Carolyn Minnick, of HRH Insurance in Truckee, agrees.

“I have worked diligently with the hospital about insurance policies. There’s a whole variety of different coverage and plans for individuals,” she said.

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