In July, the Montana Psychiatric Association started hearing that Blue Cross and Blue Shield of Montana wasn’t fully reimbursing psychiatrists.
Helena-based psychiatrist Julian Thorne sits on the association’s board. He explains that when a medical provider bills an insurance company, they code up to a level five. The higher the number, the more complex the visit.
Thorne says that's "based on number of diagnoses addressed as well as, like, tests ordered, if there were tests, medications managed, that kind of thing."
More complex care means a higher bill for the insurance company.
The Montana Psychiatric Association and the Montana Association of Pediatric Psychiatrists filed complaints with the state. The Montana Commissioner of Securities and Insurance, which regulates the industry, did not respond to a request for comment on the complaints.
The complaints allege that Blue Cross is downcoding nearly all visits to the lowest level without looking at the medical documentation showing more complex and time-consuming care was provided.
Blue Cross in a statement said it did change how it evaluates what medical providers are billing for, to "ensure claims are submitted with accurate and complete information." It said its policy complies with state and federal law.
Thorne says the result for patients could mean shorter visits with providers.
"If you're doing extra work because a patient needs it, and the insurance is not reimbursing for it, then it disincentivizes you from doing that."
Thorne says providers may also decide to no longer accept Blue Cross or insurance at all, meaning fewer choices for patients.
