Question about a problem with Blue Cross Insurance?

Question

I'm having issues with Blue Cross PPO insurance coverage, and I'm wondering if I have any options available.

In a nutshell, Blue Cross gave the approval for maternity coverage for an out-of-network doctor. The bill came back, and the doctor had charged more than the "hidden cap" that Blue Cross will pay for the benefit. Since this was an out of network doctor, I understand that I'm responsible for the amount over that cap.

HOWEVER, Blue Cross at no point stated that there was a hidden cap, nor is there a cap anywhere defined in my benefit plan. Additionally, when Blue Cross approved this coverage with an out of network doctor, they NEVER state anything about a hidden cap in their letter to me or at any other point. This being the case, are there any actions or steps that I can take to have BC cover the remaining balance, since they never indicated that there would be a hidden cap in benefit coverage?

Thanks.

Answer 1

OK. here it is... The doctor is billing you. Call the doctor, and tell them you're not ignoring them, but you weren't aware of the payment procedures for OON providers. Doctor's offices are more than aware of how out of network reimbursement work... Let them know you'll get back with them after you've tangoed with your insurance, or ask if they will do an appeal on your behalf. If they won't>>>

Then, call your insurance. Tell the person on the phone you want to appeal the allowed amount applied to your OON claim... Some companies will make you do this in writing. Some allow it over the phone... They will help you facilitate your appeal...

Either way, just state you feel like you went OON to see a doc, and to date, no one has explained the way out of network reimbursement works. Request to appeal their decision to use an allowable amount to process you claim. You letter should state you would like it paid considering full billed charges...

NOW, the kicker... Do the math... If they adjust your claim, to pay your percentage based on billed charges, your patient responsibility will go up. So, will the amount paid to the doctor. Is the difference substancial enough to warrant going through the appeal process?

Hope this helps

Answer 2

This is not a hidden cap, as you say it. When enrolled in a PPO, you need to understand that the insurance company is going to give you every incentive to use their network of providers because they have a contract with these providers regarding how much they can charge. The docs basically agree to accept what the insurance company deems as customary, without billing the insured for the difference.

When you use an out-of-network provider, you lose the advantage of that contract. Therefore, it is totally up to the doctor how they handle the balance after the insurance company pays their share. Since you chose this provider, it is your responsibility to pay the doctor anything that is not covered by your insurance.

Answer 3

I understand your frustration. However, the policy or Certificate issued to you does explain this "hidden cap" as you call it. Look in the "definitions" section for a term such as "allowable amount," or perhaps "usual and customary amount /usual and customary rate" (also referred to as "UCR"). The UCR (or whatever term the definitions section uses) is the highest amount your plan will pay to an out-of-network provider. It's supposedly based on the average amount charged by a provider in your area for the same service. Unfortunately, few (if any) states in the U.S. regulate this methodology, which leaves insurers open to determining their own UCR with no checks or balances.

I suggest you contact your state's insurance commissioner's office to inquire whether there is anything you can do, or if there are any statutes pertaining to this issue. You might also wish to send BCBS a written appeal and ask it to double check its calculations.

Answer 4

Hello,
This is a very common practice and usually the patient gets stuck with the bill... sorry about that. I would suggest sending in a letter of appeal to BCBS and seeing if that will help... then I suggest contacting the doctors office to see if they will do a write off for you. Providers offices often do take a "discounted" rate so I suggest you calling asking if they will settle for less.

Answer 5

Have your bill go before a review board of your
insurance. I would not pay for any hidden cap.
Have you checked to make sure the doctor you went to
was board certified? I went to a doctor and paid my bill. Then I received another bill for more charges
and when I questioned the additional charges I found
out that he wasn't board certified and my insurance
wouldn't cover those charges. I wasn't informed of
this at the time of the office visit. I never paid
those additional charges.

Answer 6

I think you will find that if you try to fight them you will spend more time and money than you would if you were to just pay the amount owed.

If this is a company sponsored plan you could make a formal complaint to your benefits officer and hopefully it will make a difference in that way.

Answer 7

I had issues with my BC insurance also. I know it's not what you want to hear, but fighting them is probably not going to get you anywhere. You are responsible for following all of their rules even if you weren't aware of them. When I had a problem, they referred me to a guide book that I had never even received. They said it was my responsibility to request it. I then requested it, and still never received it (almost a year later now.)