Mandated changes to Blue Cross Medicare Advantage PPO agreement announced

Blue Cross Blue Shield of Michigan is adding the following provision to the Medicare Advantage PPO Provider Agreement. This is in accordance with the requirements of Centers for Medicare & Medicaid Services regulations 42 C.F.R. § 422.2 and 42 C.F.R. § 422.222:

CMS Preclusion List. Medicare Advantage Organizations are not permitted to make payment for a health care item, service, or drug that is furnished, ordered or prescribed by an individual or entity that is included in the CMS Preclusion List 42 C.F.R. § 422.2. Should Provider be added to the CMS Preclusion List, it agrees to immediately notify BCBSM so that BCBSM may notify its impacted members. Provider understands and agrees that beginning 60 days after the notification to the member, Provider will no longer be eligible for payment from BCBSM and will be prohibited from pursuing payment from the member for any service furnished, ordered, or prescribed after that date. Provider also understands and agrees that it will hold financial liability for services, items, and drugs that are furnished, ordered, or prescribed after the 60-day period. Provider asserts that it does not now, nor will it in the future, employ or contract with providers or prescribers who are listed on the CMS Preclusion List. Provider understands that the Preclusion List will be regularly updated by CMS and agrees that it will monitor the Preclusion List and ensure that none of its employees, contractors, or prescribers are included on it. Should Provider discover that one of its employees, contractors, or prescribers has been added to the preclusion list, Provider agrees to immediately notify BCBSM. Provider shall ensure that payments are not made to providers or prescribers included on the CMS Preclusion List. To the extent that Provider contracts with other providers to provide services to BCBSM members pursuant to this agreement, it will require such other providers to comply with the requirements of 42 C.F.R. § 422.2 and 42 C.F.R. § 422.222.

Since the above provision is a CMS mandated change, it will amend the agreement 30 days after publication of this article. This is in accordance with Paragraph 7.1 of the Blue Cross Medicare Advantage PPO agreement.