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» LymeNet Flash » Questions and Discussion » Medical Questions » bc/bs says no pay if not in their system!!

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Author Topic: bc/bs says no pay if not in their system!!
randibear
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my bc/bs is ppo (preferred provider only). so my llmd is dropping insurance.

they said if he drops insurance they don't pay squat...not for tests, not for drugs, not for anything.

he's considered out of network and i have to pay everything.

that's what they said....

boy, this insurance business is getting really bad.

i have one more appointment before he drops insurance and luckily he feels i'm doing well enough that i may be able to drop treatment for awhile.

only symptoms seem to be that dang tinnitus and some facial twitching....i walk over a mile every day and do all the house cleaning and all. hubs is always gone so i'm in effect, single, so i have to take care of myself and the house.

my balance has improved greatly and i have excellent strength. mental capability is good, course i've never been the sharpest tack in the box anyway, but at least i'm not screwing up my words anymore.

so let's hope that i can get through all this.

and yes, there is hope. i've been on drugs since june of 06...with an occasional break...

--------------------
do not look back when the only course is forward

Posts: 12262 | From texas | Registered: Mar 2007  |  IP: Logged | Report this post to a Moderator
disturbedme
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It's great to hear you're doing better.

Good luck to you. And sending good thoughts!

--------------------
One can never consent to creep when one feels an impulse to soar.
~ Helen Keller

My Lyme Story

Posts: 2965 | From Land of Confusion (bitten in KS, moved to PA, now living in MD) | Registered: Jun 2007  |  IP: Logged | Report this post to a Moderator
lou
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Look at your contract. Most PPO health plans do pay for out of network docs, etc. but they pay at a lower rate. This sounds questionable to me, so be sure to look at your contract. This might be true for an HMO plan or sometimes a basic BX plan, but the only way to check on them is to read your contract. And if they are handing you a line, your state insurance commissioner may get involved.

And I don't think testing or meds would be affected by using an out of network doc, unless you got these from out of network sources.

Posts: 8430 | From Not available | Registered: Oct 2000  |  IP: Logged | Report this post to a Moderator
Michael_Venice
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I agree with Lou. Certainly don't give up based on what your doctor tells you.

My doctor has told me things about insurance that have turned out not to be true.

Posts: 322 | From Venice, CA | Registered: Sep 2008  |  IP: Logged | Report this post to a Moderator
jt345
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Hi

Im my opinion(not a doctor ,only a chronic lyme person) If He has twitches in His face ,Then He has nero lyme . It has reached His brain.

From My expereience it will not go away on it's own.

Find a LLMD,or He will end up like Me and countless others,Disabaled.

I do not mean too scare You,Iam just relaying what happened too Me. Lyme since 1988,treated since,sometime around 1998,I don't remember. Or maybe it is something else. Only an experienced Doctor in tick born illnesses can give You that imformation.

This nothing too play with.
appleseed

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randibear
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i've been treated since 2006 and recently found a great doc in denton.

but it was the bc/bs lady and not my doc who said they are changing policies and me being federal i don't have a contract, just a book. it's states they pay about 10%, which is squat, and if he's not a ppo they won't pay for tests which he orders cause he's technically not "authorized" to cause he's not a ppo.

talk about a circle.....

--------------------
do not look back when the only course is forward

Posts: 12262 | From texas | Registered: Mar 2007  |  IP: Logged | Report this post to a Moderator
1Bitten2XShy
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WOW, I have BCBS PPO and they pay 100% for all bW thru Quest only...even out of network Dr,'s or those that do not take insurance.
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lymednva
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I have BC/BS PPO also and they pay 50% out of network visits and between them and Medicare all my testing gets covered, even Igenex! Also meds are covered no matter who rx's them

--------------------
Lymednva

Posts: 2407 | From over the river and through the woods | Registered: Apr 2006  |  IP: Logged | Report this post to a Moderator
JillF
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when i had bc/bs hmo they would not pay for my out of network llmd but did pay 100% for all blood work (as long as i went to labcorp or quest) and all prescriptions minus copay

now that i have bc/bs ppo, they pay 80% of out of network doctors (after the $2k deductible) and still pay for all blood work and prescriptions minus copay. does not matter who the physician is - in network or out of network. they do not cover igenex though

what you were told just doesn't sound right

you might even be able to log onto their website, register your info, and see what your plan includes (which will also tell you what out of network services your plan provides)

the handbook might also be on the website

http://www.bcbs.com/coverage/find/plan/

Posts: 1485 | From USA | Registered: Apr 2004  |  IP: Logged | Report this post to a Moderator
lou
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That "book" is your contract. With Blue Cross, you can have a PPO that is basic (pays less), standard (pays more), or HMO which pays nothing out of network for docs (but apparently some on the right labs, etc according to others on this thread.) I don't personally know anything about HMOs, BX or otherwise.

It does not sound to me like you have a good grip on your plan. Is there anyone you can ask to help you, like the human resources people in your agency? Or someone else who has this kind of insurance? The statement about BX changing plans on you is very puzzling. The customer chooses the plan, not the agency or the insurer under a federal system.

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randibear
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they didn't say they were changing my plan which is code 104. they said they were putting me into a high risk category and going to assign a case manager to me.

i've read that entire book and it doesn't say anything about a case manager or being put in a risk category group.

it does say they will pay up to 30 percent of non-preferred providers.

but the lady i talked to said if he is not accepting insurance that i pay all expenses first and then submit paperwork for "review"....

i've done this before and i did not get any money back and when i called they said "well he's out of network so we're not paying. it's up to us to make the determination." they would not pay for the igenex either because this doctor was out of network.

i guess it depends who you talk to on a specific day.

i had one woman that told me she had worked for bc/bs and they really do put flags and colors on your file if you file too many requests for payment.

--------------------
do not look back when the only course is forward

Posts: 12262 | From texas | Registered: Mar 2007  |  IP: Logged | Report this post to a Moderator
billclo
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I had huge hassles w/getting reimbursed for treatment from BC/BS. It worked out to be about 30% of their "customary charge" - NOT what the doc charged, AFTER they applied the customary charge - NOT what the doc charged - to my deductible. I ended up submitting many forms - they "lost" them on a regular basis, reimbursement took months, and I ended up seeing only about 10% reimbursement of my total doc charges.

They did somewhat better on my lab tests, depending on which lab it was; some they covered nearly 100%, some nearly nothing.

I ended up submitting my claims to a manager directly as the regular billing peons were screwing things up so regularly. I told her that I believed I was being persecuted for having Lyme's and that I was considering putting together a class-action suit over it. [Smile] Service got perceptibly faster after that.

If I wasn't fairly well-off and able to pay for the treatment - not what the insurance was willing to pay for, I'd probably be either dead or crippled.

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TerryK
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Sorry you are having trouble with your insurance company.

They are obligated to follow the contract. It is not up to them to decide if they are going to pay or not based on whether he is out of network. They must pay whatever the contract shows for out of network providers. As already mentioned, they decide what is the usual and customary fee and base their percentage on that.

They can say that your treatment is not medically necessary and that is a loophole that many of them use (thank you IDSA!).

I think most of the insurance companies go for the low hanging fruit. They try to deny initially because they figure a certain percentage of claimants will go away without a fight. After all, they are dealing with sick people who are often not up to fighting.

If you put up a fight, they may back down. It could take some time and aggravation though.

Keep good notes with names and dates when talking with the insurance company. Make them send denials in writing with the reason for the denial even though they may try to refuse. You may have to keep insisting.

Keep asking them questions until you understand exactly what the basis for denial is. Ask for them to point to the page in the manual that applies to your denial. Keep on them. There is some validity to the squeaky wheel gets the grease saying.

Terry

Posts: 6286 | From Oregon | Registered: Jan 2006  |  IP: Logged | Report this post to a Moderator
   

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