It sounds surreal, but it's true.

Clinicians in the 14 Anthem BCBS states are discovering this truth in record numbers. And are, understandably, concerned. For background, check out my January newsletter.

Even if you're not in an Anthem a/k/a "Elevance" state, this could easily happen to you also. And probably has - without you ever knowing about it! If you've ever wondered how a client came to you from a network you never heard of, this is probably how it happened.

The legalese in provider contracts that gives them the right to sell your participation is called the "assignment clause." It goes something like this:

"...this agreement may be assigned by [payer name] at any time, to an affiliate or successor ..."

Then,

" ... the agreement will survive without any change in terms for products/lines of business designated by [payer name] as a participating provider agreement with the Affiliate or successor for the products/lines of business managed by these entities."

Are your eyes glazing over yet?

The paragraph, typically fairly short, ends with the payer stating they will provide advance notice to the provider / group. (How generous.)

What does any of this even mean?! Do I need to be worried?

• It means that if the payer merges with someone else, or is bought by another entity, then you will now be part of the new entity - automatically!

• It also means that the payer can rent their network to anyone who chooses to pay them for the privilege - and you will automatically be participating with the renter corporation.

Typically, when an "assignment" happens, the clinician / practice gets a letter, which provides an opportunity to opt out. The problem is, the language is equally obscure and difficult to decipher without a law degree.

I've never yet seen a payer that did not allow opt-out at the time they provided the notice. I'm no lawyer, but I suspect that despite what the contract implies, the law probably requires the payer to allow the practice to opt out. (at least in some states).

What can I do about it?

When you enroll with a network, nothing. "Assignment" is going to be in the contract. But as soon as you receive a notice, read it carefully! Hint: a lot of these notices seem to arrive in mid-November through the end of the year, announcing changes for the new year. Seems to me this timing is intentional - payers know people are busy during the holidays.

In the case of Anthem/Elevance becoming Beacon/Carelon, the letters include a FAQ (in every state I've seen, so far). The FAQ explains that yes, as a result of the assignment, your practice will now participate with Beacon/Carelon. BUT, KEEP READING...!

Anthem doesn't highlight it with a neon arrow, but the FAQ eventually indicates that if the clinician does not want to participate with Beacon, there is an email address where you can send a request not to be added. Sending an email - yes, that's really all there is to it.

But if you plan to opt out, notify any client who you think might be affected. Preferably in writing. Tell them you were drafted into Beacon's network as a result of a corporate merger. And that you have opted out.

Because your client's claims will be affected almost immediately.

Last week I attended one of the integration webinars offered by Beacon/Carelon. This one was for New York - Empire BCBS. During the chat, someone must have asked at least once per 5-10 minutes during the 60-minute webinar "Do we HAVE to participate with Beacon if we don't want to?" The answer was clear - you do not - but was stated in a confusing, jargon-laden, and roundabout way. They reiterated that clinicians should send an opt-out request to the designated email box. But, time appears to be a critical element. In New York, the "assignment" of the Empire contract happened on April 1, and the Beacon participation does not begin until 45 days later. Judging on what I've seen in New York and other Anthem/Elevance states, the teams handling the integration are seriously overwhelmed.

So, if you are a New York practice who withdraws now from Beacon/Carelon, who knows how long it will be before your opt-out is acted upon, processed, and loaded into the claims system? As the clinician, you'll be left with a difficult dilemma: do you honor an assignment to a network you never intended to join? Just because some huge entity merged? Therefore losing money in the process? Put another way: you'd be honoring the signature on a legal contract. But it was more than likely a "take it or leave it" affair, to which you were not an equal party. And depending on client composition & volumes, this could have a significant negative effect on a practice.

And yet, on the other hand, what about the client? If you decide to proceed as if you are still out of network during the time that it takes Carelon to update your status, how (or will?) that affect the client's reimbursement?

Eventually, of course, Carelon will update you. If they make your opt-out retroactive to the date on your email, then claims can be re-worked to the out-of-network level. But given the immense workload in front of Carelon at the moment, "eventually" could be quite a long time.

It's a tough choice! Especially if there is a negative financial impact on your client. This seems to me a critical question to ask state license boards and malpractice attorneys. And possibly someone in your discipline who specializes in client ethics.

A few practical suggestions:

• Follow up! Repeatedly! I recommend every 30 days.
• Record the name of the customer service rep you speak to, including last name (first initial), and a reference #.
• Keep the documentation.
• Ask for a supervisor after you have called 2 or 3 times.
• Ask if they will be making your opt-out retroactive to the date you sent in the request.
• Keep filing claims! You don't want to fight "timely filing" denials on top of everything else. Claims can always be adjusted after the fact. "Waiting for Provider Relations" will not be deemed an acceptable reason to file late.

For more practical advice on dealing with the Anthem / Elevance and Beacon / Carelon snarl, click here for a free download.