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A view of UMass Memorial Medical Center in Worcester in 2015.Pat Greenhouse\/Globe Staff\/file 2015<\/p>\nThe dispute represents another front in the battle over spiraling health care costs and who \u2014 insurers, providers, or patients \u2014 should bear the brunt of efforts to control them.<\/p>\n
For patients, it raises the possibility that they will have less time with their doctors as physicians get caught up justifying billing practices or choose to steer clear of more complicated cases. <\/p>\n
Several doctors were particularly upset that they won\u2019t learn that their payments have been cut until they receive them.<\/p>\n
\u201cThe thing that feels so frustrating,\u201d said Dr. Aaron Bornstein, a partner in Middleboro Pediatrics, \u201cis you\u2019re found guilty before having a chance to prove your innocence.\u201d<\/p>\n
Blue Cross says doctors will have the right to appeal its decisions and that the vast majority of the more than 32,000 physicians in its network will not be affected by the program. <\/p>\n
\u201cEnsuring that our members have access to safe, effective, and affordable care is our top priority,\u201d Blue Cross said in a letter it sent last month to 16,000 providers. <\/p>\n
Blue Cross faces serious financial problems. It reported an operating loss of more than $400 million for 2024, the largest in its history, and this month offered buyouts to hundreds of employees. <\/p>\n
Physicians bill insurers using codes that reflect the complexity of medical cases and the amount of time they require; the higher the code, the higher the charges.<\/p>\n
Dr. Sandhya Rao, chief medical officer for Blue Cross, told the Globe that doctors billing at the two highest codes \u2014 Levels 4 and 5 \u2014 has surged since 2021. During that period, the insurer\u2019s costs per office visit rose 30 percent, Rao said. <\/p>\n
Level 4 cases have \u201cmoderate\u201d complexity and risk of complications, while Level 5 cases have \u201chigh\u201d complexity and risk of complications, according to codes developed by a panel funded by the American Medical Association.<\/p>\n
Under the new program, Rao said, Blue Cross will review claims from providers who \u201croutinely bill visits at the highest complexity levels (4 and 5).\u201d If the medical cases do not support that level of severity, she said, Blue Cross \u201cwill edit the claim\u201d to pay one level lower than originally billed.<\/p>\n
Rao declined to say how much an \u201cedit\u201d would lower payments to doctors. Blue Cross doesn\u2019t make its fees public, she said. <\/p>\n
Rao estimated that no more than 2 percent of the roughly 7,600 primary care physicians and no more than 4 percent of the roughly 25,000 specialists in the insurer\u2019s network will be flagged for overbilling. <\/p>\n
To carry out the program, Blue Cross is paying a Utah-based company, Cotiviti, which uses an algorithm as well as registered nurses to analyze claims, compare them to those of peer doctors, and identify physicians who overcharged, according to Amy McHugh, a spokesperson for the insurer. <\/p>\n
In doing so, Blue Cross is engaging in a bit of high-tech tit for tat; Rao said that some of the physicians it plans to scrutinize may be charging higher fees because they rely on AI-powered transcription tools that listen to conversations between doctors and patients to automatically generate clinical notes. Those tools, she said, sometimes categorize appointments as more complex than they were.<\/p>\n
McHugh said physicians\u2019 contracts with Blue Cross prohibit doctors from making up the difference in lowered payments by passing the costs on to patients.<\/p>\n
The state\u2019s second-biggest insurer, Point32Health, parent company of Harvard Pilgrim Health Care and Tufts Health Plan, said it doesn\u2019t unilaterally \u201cdowncode\u201d claims if it suspects doctors have charged too much; rather, it holds up payments and asks the doctors to submit medical records for review, according to Kathleen Makela, a Point32Health spokesperson.<\/p>\n
Physicians, mostly in primary care, denounced the Blue Cross program. <\/p>\n
Dr. David Weinstock, a primary care physician who has worked at a small private practice in Auburn for 22 years, said he sees five to 10 patients a week whose visits he classifies as \u201cLevel 5\u201d in bills to insurers. <\/p>\n
It\u2019s appropriate, he said, because he can easily spend 40 minutes working on each case. Not only does he examine the patient and discuss the individual\u2019s medical problems, he has to review lab test results and other records before and after the visit, and sometimes consult specialists.<\/p>\n
\u201cIt\u2019s not uncommon to see some patients who have 15 chronic health issues,\u201d said Weinstock, an assistant professor at UMass Chan Medical School in Worcester. \u201cWe have more and more older patients, sicker patients, and complicated patients.\u201d<\/p>\n
Several primary care doctors vowed to fight Blue Cross if the insurer lowers payments. To leave that unchallenged, the physicians said, could cost them thousands of dollars a year. But appealing a decision, they said, will only add to their administrative burdens. <\/p>\n
Dr. Frank Domino, a family medicine physician in Shrewsbury, said he already receives a letter from Blue Cross every six months saying that he bills at a higher-paying code than many of his peers.<\/p>\n
\u201cMost of my patients I\u2019ve had for 30 years, and they have multiple medical problems,\u201d said Domino, 65, who is affiliated with UMass Memorial Health in Worcester.<\/p>\n
A view of UMass Memorial Medical Center in Worcester in 2015.Pat Greenhouse\/Globe Staff\/file 2015<\/p>\n
He randomly pulled up the computerized records of a 62-year-old woman he saw last December. She had knee pain, damaged veins in her legs, liver problems, and asthma. Domino said he spent 45 minutes on her case, which he classified as Level 5. <\/p>\n
Domino said he relies on a UMass Memorial Health billing office to make sure he submits claims correctly. Nonetheless, he predicted that Blue Cross will categorize him as one of the outliers. <\/p>\n
\u201cIt\u2019s intimidation,\u201d he said. \u201cIt\u2019s like organized crime.\u201d<\/p>\n
The Massachusetts Medical Society, which represents 24,000 doctors and medical students in the state, has expressed concern about the Blue Cross program and met twice with the insurer in recent weeks. The group is planning to hold a third meeting with Blue Cross in January, about two months after the program starts. <\/p>\n
Several national and local groups of allergists, including the Massachusetts Allergy and Asthma Society, recently wrote Blue Cross urging the insurer to \u201crescind this program immediately.\u201d The allergists said the initiative lacked transparency and threatened to worsen physician burnout with added administrative work.<\/p>\n
Rao, of Blue Cross, did not address the request to rescind the program in a written reply. But she said that audits by federal agencies, including the Centers for Medicare & Medicaid Services, have found that a \u201csignificant amount\u201d of the highest-paying claims have been coded incorrectly by doctors.<\/p>\n
Lora Pellegrini, president and chief executive of the Massachusetts Association of Health Plans, which represents 13 insurers in the state excluding Blue Cross, said the intensified scrutiny of physician billing isn\u2019t happening in a vacuum.<\/p>\n
The Massachusetts Health Policy Commission, an independent state agency working to improve the affordability of health care, identified overbilling as a contributing factor to higher costs in a 2021 report. State officials should examine whether claims submitted to insurers were consistent with the severity of medical cases, the report recommended. <\/p>\n
Two of the nation\u2019s largest health insurers, Cigna and Aetna, which both operate in the state, recently launched programs similar to Blue Cross\u2019s. Those efforts provoked blowback from doctors outside Massachusetts.<\/p>\n
Indeed, Cigna temporarily paused the start of the program on Oct. 1 for some customers in California after it drew fire from multiple medical organizations, including the California Medical Association.<\/p>\n
Some primary care doctors in Massachusetts said the care they provide saves the health system money by preventing patients from getting seriously ill and seeking far more expensive care from specialists and hospitals.<\/p>\n
\u201cWhen primary care is thriving, we keep people out of the emergency department and prevent unnecessary hospitalizations,\u201d said Dr. Wayne Altman, chair of family medicine at Tufts University School of Medicine, who practices in Arlington. \u201cThose are huge-ticket items. If they\u2019re trying to control costs, they\u2019ve come to the wrong place.\u201d<\/p>\n
This story has been updated.<\/p>\n