Although the policy has been part of the company’s commercial PPO hospital agreements for years, it has not been enforced, the insurer told Becker’s. The policy will apply to all in-network hospitals in Michigan, starting March 1.
Under the new enforcement, when an in-network hospital disagrees with Blue Cross’ reimbursement decision regarding the medical necessity of services, the hospital can request an external review by a panel of practicing physicians. If the review supports Blue Cross’ decision, the hospital will be responsible for paying the cost of the review. If the review overturns Blue Cross’ decision, Blue Cross will cover the review cost.
As in the past, first-level appeals will remain free for providers, and hospitals will also have the option of requesting a peer-to-peer review at no charge. Blue Cross noted that 85% of external second-level appeals in 2024 upheld the company’s original decision.
