February 25, 2014



I received a letter from BCBS they are terminating my contract.  I have participated with them for 18 years, many of my patients are BCBS patients and now as of January 1, 2015 I will be out of the network.  What can I do?

Please address.

Dr. A


First, you are not alone.  Termination of participating provider contracts is happening for small practices, large practices and IPAs everywhere.  As the health plans shift around money and begin to negotiate higher rates for some, money for others has to decrease to even out.  Similarly, many of your patients are losing coverage.  Most small businesses (under 50-100 employees, which is most businesses - likely yours), will lose their current health plan option by 2015 (unless Obamacare is pushed again).  The general state of panic we are in over coverage will not resolve itself until we understand plan options for businesses and patients, and who knows when that will settle out (maybe 1-2 years?).  So, the bad news, you may be kicked out of network, may be set off by the fact of, so will your patients.

Second, you can challenge the determination.  Our office is available to assist in your appeal.  Now, I caution here because I do not like seeing clients throw good money towards a bad fight.  By challenging, we may not have a contract claim to stand on - the carrier may have terminated you properly, by providing proper notice.  You may recall the recent CT case where medical societies were successful enjoining a carrier from terminating par docs, and the basis of the positive result was the carrier was in breach of contract by providing improper notice. There are arguments our firm is looking in to that are ERISA based, and otherwise to assist in carrier termination issues.  Also, I recommend collecting letters of support from your patients and community, and contacting local politicians and the Attorney General. 

Third, do not take your termination in your practice bubble.  Step outside and educate yourself on the emerging marketplace.  There are a number of IPAs in your vicinity that are accepting membership and will (presumably) have clout to negotiate your participation in large carriers (the same as may be terminating you).  Get out there and get information! 

Tonight, I am speaking at the first reception for the South Nassau / Winthrop Physician Hospital Organization meeting.  I will discuss this topic a bit further and we will get an opportunity to meet the PHO together.  Join me to see whether this local option is a good fit for your practice. 
Here is the info, be sure to RSVP -

Cocktails & Hors d'oeuvres: 6:00 p.m.
Speaking Engagement: 6:30 p.m.
Conference Center B & C
South Nassau Communities Hospital
One Healthy Way, Oceanside, NY 11572
RSVP to Provider Relations at South Nassau PHO, Inc. (mention you heard about this from our newsletter and receive a free Red Flag Policy!)
SNPHO@snch.org or (516) 632-4PHO (4746)