Settlement Reached on Major Blue Cross/Blue Shield Antitrust Lawsuit- AHA Webinar November 20

After more than a decade of litigation, the national Blue Cross Blue Shield Association (BCBSA) agreed to a proposed class action settlement that would distribute $2.8 billion to impacted hospitals and providers and require substantial changes in the way the health insurers conduct business. The American Hospital Association is hosting a webinar for AHA member hospitals November 20, 1:30 pm to provide more information regarding the settlement. Prior registration is required for the webinar here.

The BCBSA includes among its local affiliates Premera Blue Cross and Regence Blue Shield. According to the settlement document, any provider who treated a BCBS member from July 24, 2008 to Oct. 4, 2024 is eligible for a portion of the settlement. Washington hospitals may be eligible for recovery as a member of the class. WSHA will provide additional information on options to hospitals once the proposed settlement receives preliminary approval by the court.
The settlement amount for a particular hospital or provider group will depend on the ultimate size of the class and the distribution methodology. Some hospitals and providers may opt out of the class settlement and pursue separate settlement if they believe they can successfully demonstrate financial harm. More information will be available once the settlement is approved by the court and the allocation details are known.

In addition to the monetary settlement, the settlement agreement requires the BCBSA to make significant changes to its rules to allow greater competition between plans and requires greater infrastructure and accountability for payment for services for enrollees of out of area plans contracted through the BlueCard system. The BlueCard changes include greater accountability for including prior authorization and timely payment of claims. Though the monetary settlement is significant, these operational changes may be of greater impact to hospitals and providers. WSHA will provide additional information as it becomes available. (Andrew Busz, andrewb@wsha.org)

PQAC Continues Progress on Rulemaking Regarding Acquisition of Provider-Administered Drugs

The Pharmacy Quality Assurance Commission (PQAC) is making progress on rulemaking regarding alternative distribution of provider-administered drugs, often referred to as “white bagging or “brown bagging.” WSHA is generally supportive of this increased regulatory oversight.
A PQAC alternative distribution workgroup, which last met October 31, is developing requirements to address patient safety concerns when the facility or provider administering a drug does not have an uninterrupted chain of control. This lack of control occurs when the drug is transported through mail or common carrier rather than through the facility or provider’s own supply mechanisms. This is a significant issue as insurers are increasing requiring facilities and providers to obtain provider-administered drugs through the insurers’ specialty pharmacy as a condition of payment.

The draft rules, when completed by the workgroup, will be sent to the full PQAC for discussion.   WSHA will continue to monitor the process to ensure that Office of the Insurance Commissioner rules regarding health carriers align with the new requirements and restrictions. (Andrew Busz, andrewb@wsha.org)
 

OIC Proposed Rules for HCBMs, Balance Billing, and Prior Authorizations

The Office of the Insurance Commissioner recently released notices of three sets of proposed rules to implement legislation supported by WSHA. WSHA has been closely monitoring the rulemaking process to ensure the rules conform to the legislation. The notices include information on how interested parties can comment or testify at the rulemaking hearings scheduled for late November or mid-December. The proposed rules include:
Health Care Benefit Managers (HCBMs).  The proposed rule:

  • Adds new reporting and notification requirements for health care benefit managers and health carriers that use them
  • Expands appeal mechanisms and protections for pharmacies appealing decisions of pharmacy benefit managers
  • Creates a process for self-funded groups to elect to participate in the pharmacy protections

Balance Billing Protection Act Expansion.  The proposed rule:

  • Adds behavioral health services and ground ambulance services to the balance billing prohibitions under the state’s Balance Billing Protection Act
  • Adds minimum payment requirements for carriers for out of network ground ambulance services
  • Modifies the standard BBPA notice of consumer rights to include behavioral health and ground ambulance services.  The updated notice, which should be used effective January 1, 2025, is available here.

Prior Authorization Modernization. The proposed rule:  

  • Adds prescription drugs to health carrier prior authorization timeliness and reporting requirements
  • Defines electronic prior authorizations
  • Reduces health carrier response timeframes for electronic prior authorization requests. The reduced timeframes were effective January 1, 2024.  More information is available here.

A comprehensive listing of rulemaking WSHA is participating or monitoring is on our Regulatory Issues page. For a listing of existing and planned bulletins and other implementation resources, see our New Law Implementation Guide. (Andrew Busz, andrewb@wsha.org)