Federal Blue Cross/Blue Shield

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bartbill
Posts: 44
Joined: Fri Apr 02, 2010 11:52 pm

Federal Blue Cross/Blue Shield

Post by bartbill » Sun Jul 29, 2012 3:04 pm

This has to do with "non-participating providers": I just received a bill from a non-participating provider for hospitalization in Long Beach when I was vacationing there in June. Had no clue he had performed a service. This happened to me a couple of years ago on the West Slope - even though I told them I wanted only BS/BS providers. I'm sure I'm not the only one hit by these little surprises in the mail a month or so after a hospitalization. I'd like to know the best way to handle this.

I'm planning a vertebra fusion I in August. The doctor's office seemed less than thrilled (annoyed may be more accurate) that I wanted assurance only plan participants be involved. Lots of experienced and seasoned folks on this board; how have you handled it?

Regards

stan1
Posts: 5697
Joined: Mon Oct 08, 2007 4:35 pm

Re: Federal Blue Cross/Blue Shield

Post by stan1 » Sun Jul 29, 2012 4:11 pm

I'd check with the hospital you will have the surgery at. They will know more about whether all the specialists who practice there are BC/BS preferred providers. The surgeon you are working with probably does not have any control over which anesthesiologist or radiologist is on duty at the hospital, or which lab the hospital uses.

retiredjg
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Joined: Thu Jan 10, 2008 12:56 pm

Re: Federal Blue Cross/Blue Shield

Post by retiredjg » Sun Jul 29, 2012 4:25 pm

bartbill wrote:This has to do with "non-participating providers": I just received a bill from a non-participating provider for hospitalization in Long Beach when I was vacationing there in June. Had no clue he had performed a service.
1) You could talk to his billing office and see if they will accept the participating plan payment or at least a reduced fee. Emphasize that you had "no clue he had performed a service" and therefore could not have knowingly authorized it.

2) Alternatively, you could see if BC/BS will just pay it since this was obviously an unplanned event and you had no control over the selection of this physician.

3) Or, explain it to BC/BS and see if they will negotiate with the doctor's office.


I'm planning a vertebra fusion I in August. The doctor's office seemed less than thrilled (annoyed may be more accurate) that I wanted assurance only plan participants be involved. Lots of experienced and seasoned folks on this board; how have you handled it?
I'd call BC/BS and ask them in advance about the best way to plan and handle this. My experience has been they are very helpful.

On the other hand....you have chosen a participating physician and facility, right? There should not be any doctors involved that you have not already had contact with. Yes, I know sometimes doctors will switch around, but you could request that only your chosen physician do the work (or at least the billing).

Edit: I had forgotten about the anesthesiologist, etc. However, my experience has been these people are participants if they are working at a participating facility. I gather that may not always be true.

bartbill
Posts: 44
Joined: Fri Apr 02, 2010 11:52 pm

Re: Federal Blue Cross/Blue Shield

Post by bartbill » Sun Jul 29, 2012 7:33 pm

Thanks all for the quick replies,

Yes, the doctor and the hospital are participating, but as you say, they don't pick the labs etc. BS/BS said a process called "spinal imaging" is one group most folks don't know about . And many that provide this service are not participating. Think the thing to do, as suggested, is wait until the surgery is scheduled, then contact the hospital directly to see who will do the various duties.

Curious as to why BC/BS appears not to interested in this on behalf of its insureds. Seems as more and more health providers opt out of participating insurance becomes less valuable. I'm venting now, I know

Thanks.

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HueyLD
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Re: Federal Blue Cross/Blue Shield

Post by HueyLD » Sun Jul 29, 2012 7:44 pm

According to this Fed BCBS site ( http://www.fepblue.org/about/glossary/t ... sary.jsp#n ):
Note: For certain covered services from Non-participating professional providers, your responsibility for the difference between the Non-participating Provider Allowance (NPA) and the billed amount may be limited.

In only those situations listed below, when the difference between the NPA and the billed amount for covered Non-participating professional care is greater than $5,000 for an episode of care, your responsibility will be limited to $5,000 (in addition to any applicable deductible, coinsurance or copayment amounts). An episode of care is defined as all covered Non-participating professional services you receive during an emergency room visit, an outpatient visit or a hospital admission (including associated emergency room or pre-admission services), plus your first follow-up outpatient visit to the Non-participating professional provider(s) who performed the service(s) during your hospital admission or emergency room visit.

When you receive care in a Preferred hospital from Non-participating professional providers such as a radiologist, anesthesiologist, certified registered nurse anesthetist (CRNA), pathologist, neonatologist or pediatric sub-specialist; and the professional providers are hospital-based or are specialists recruited from outside the hospital either without your knowledge and/or because they are needed to provide immediate medical or surgical expertise


When you receive care from Non-participating professional providers in a Preferred, Member or Non-member hospital as a result of a medical emergency or accidental injury (see page 73 of the Service Benefit Brochure).


For more information, see Differences between our allowance and the bill in Section 4 of the Service Benefit Plan brochure.

bartbill
Posts: 44
Joined: Fri Apr 02, 2010 11:52 pm

Re: Federal Blue Cross/Blue Shield

Post by bartbill » Mon Jul 30, 2012 10:31 am

Thanks much,

I am aware of that. All I want is providers who play ball with the insurance companies and thereby keep me considerably under the 5K cap.

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