Government Relations
Med Solutions Has Arrived in Washington State
Justin Smith, M.D., President WSRS
July, 15, 2011
· As of August 1, 2011, Cigna/Great West has determined to partner with a RBM, MedSolutions. Cigna handled this material financial and administrative change to business as an announcement, which is a unilateral amendment to the contract and therefore, a breach of contract. NOTE that this is the case for any boilerplate Cigna contract – this is not a case where you could say that it varies by contract. To implement MedSolutions, Cigna needs to complete mutual contract amendments with its contracted providers. However, as detailed below, Cigna’s implementation of MedSolutions is more appropriately called, “MedSolutions building radiology provider network in Washington State.”
· MedSolutions is currently under investigation in the State of Delaware where, according to published newspaper articles, the Insurance Commissioner and the Legislature found that MedSolutions, as a contractor to Blue Cross Blue Shield of Delaware, failed to approve medically necessary, covered services to the point that patients were harmed in order to achieve savings thresholds.
· Cigna/Great West is handling this MedSolutions implementation in an unprecedented way in our market. They are replacing their direct contracts with the radiologists for global services and technical with direct contracts with MedSolutions – this means that MedSolutions is sending the radiology groups direct contracts and MedSolutions will become the lease network, the claims administrator, and the utilization manager. They will not only process claims for high tech diagnostic imaging, but for all imaging services, including plain film.
· Once a provider signs a direct contract with MedSolutions, it can immediately replace the provider’s contract with Aetna (MedSolutions has been Aetna’s RBM for years) and it can be used for any other payer to whom MedSolutions desires to sell their newly created radiology network. MedSolutions rates as contained in their boilerplate mailings to the radiology community are at unprecedented lows.
· Cigna/Great West and MedSolutions communication about the scope and breadth of the contract MedSolutions has mass mailed to the radiology community has been less than forthright. It would be very easy for a radiology group to assume that the MedSolutions contract is only for Cigna membership and only for high tech diagnostic imaging when it is in fact an all encompassing agreement. Since Cigna/Great West constitutes approximately only 1% of the commercial market in WA State, this implementation can seem like a pretty small issue to those who do not have a full grasp of the situation.
· Cigna/Great West has stated that they want to maintain their direct contracts with radiology groups for “read only” services since they are going to continue to process those claims internally. This allows Cigna/Great West to have their cake and eat it too because they have to assume that not all radiology groups will sign contracts with MedSolutions, so they are covering are trying to cover their backsides from having situations where the hospital is in-network, but the hospital-based radiologist is not in-network. Thus, Cigna/Great West is playing an extremely provider unfriendly game in which they have effectively terminated their contracts with radiologists for all services except read only services and the provider loses in every way.
· Cigna/Great West states they are not doing any communication with members/patients about this upcoming change that will materially impact their imaging benefits. The payer claims it is the job of the employer group to provider such information of the membership.
· Cigna/Great West is doing this implementation nationwide. It is a corporate initiative.
· Regence and Premera are watching this situation and it is an excellent bet that should Cigna succeed in moving all of its global radiology to a RBM network, Regence and Premera will follow soon after with having their RBM, AIM, demand direct contracts in order for radiologists to remain in-network. If this market change succeeds, we could shortly be in a situation where the radiologists in Washington State no longer hold contract with payers, but with just two RBMs – AIM and MedSolutions.
· In a direct RBM contract, it is expected that services will be authorized only with the groups that have accepted the lowest rates in their region no matter which radiology group is requested by the ordering provider, causing massive volume losses for groups that successfully negotiated adequate rates with the RBM.
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Brad Boswell
WSRS Lobbyist
PO Box 22217
Seattle, WA 98122
Email Me
(206) 300-6270
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