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» LymeNet Flash » Questions and Discussion » Medical Questions » Urgent! BC/BS has taken Dr. J NC out of network

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Author Topic: Urgent! BC/BS has taken Dr. J NC out of network
char
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Dr. J Charlotte patients:

I want to let you know that Blue Cross/Blue shield has taken Dr. J out of network.

This change is in effect immediately.

For us, this change means our visits will cost $200 each out of pocket.

Our family, with the 3 of us, have decided to change back to the good LLMD who initially diagnosed us. She is 4 hours away in a different state.

If you have BC/BS insurance; check out what this will mean for you.

Those patients who have had appts this month were surprised by the change and no alternative but to pay out of pocket.

This change applies to Lyme and HIV patients.
Not good news.

Char

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newdurham77
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Still, doesn't the insurance cover 80% even for out of network doctors?
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ConnieMc
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BCBS is different from state to state. Are you saying all BCBS companies in the entire country are no longer paying?

Let me tell you this ... those AIDS patients will be outraged by this. Rest assured, they will not prevail. Sure Dr. J will sue as well. For breach of contract. I hear they owe him over a million dollars.

In any event, if he is now out of network, they will still have to pay some of the visit, depending on your deductible and coinsurance. The out of pocket payments will just be higher. So check this out first before making any big changes.

I see no way they can get out of paying things they previously approved. I noticed they haven't processed my J Clinic March visit, but already paid for one I had 2 weeks ago.

I also heard they were awaiting results of the medical board hearing, and had withheld payment.

Our family pays $500 a month for that insurance, and my husband's is free as he is the state employee under the plan. Their actions are criminal. It is all about money. They could care less about our health.

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char
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New Durham-

Connie-

My husband found out about this because he happened call them today. I may not have all the details straight.

But the thing I am sure of is that Blue Cross has made Dr. J an out of network practice. I talked to an administrator at Dr. J's and she said this is huge and affecting so many people adversely.

Plans are different, so changes will affect patients differently.

An adminstrator there just told me that they may be forced to make everyone pay up front and then file the insurance. They could even get to where they will have to accept only cash. They could be forced to close practice. Blue Cross owes Dr. J $1,000,000.

I hope that you are not affected adversely with the changes, new, Connie and all my friends here.

Char

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mimi
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I just posted about this in general. I received

a call today from them. I just got a picc line

put in last Wed. and began IV treatment. I was


supposed to go back Wed. to get my second med. I


only had 28 days so we were trying to get all we

could. I was told I now have to pay for

everything since last Wed. and pay for everything

up front from now on. I need to know how to


appeal to BCBS to keep doing treatment. I feel

horrible I just broke down on the phone I will


have to have the line pulled and I have no idea

how I will pay for the treatment so far. I

gave up a great three week job just to do the

treatment so I was already financially


strapped. Anyone know how to beg the insurance

that I pay for each month to at least pay for

what I had already started? I needed to do the 28

days [cussing]

Sorry but I am so upset there is not anyone else

close for me to see that they will pay for.

Take care
mimi

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char
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Mimi-

IM SORRY! I have been thinking of the effect on IV patients today. Not so bad for us doing better on orals.

Listen, we had to pay out of pocket for IV abx for 2 of us at one time and you can get them from certain homehealth agencies for much less than Dr. J's. Rocephin can be had for under $50 per dose for ex. These companies take credit cards. We did it in VA and NC.

There is hope-hang in there!

I have gone into the specifics of how we got IV meds much cheaper ala carte than the package deal they give. Try a search. I am going out to take kids to dr. If you would like to PM me I will check tonight.

Char

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shizuko
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I am sorry to hear the "BAD" news about BCBS.

Each local area BCBS is independent and managed somewhat differently.

But seeing out-of-network usually means the same thing. You will be reimbursed for 80% (or whatever your policy states) of what is considered as standard by the insurance company.

This standard is almost always lower than what your doctors would normally charge you.

Some out-of-network doctors ask you to pay the whole amount upfront and file a claim yourself with your insurance.

Some others, though not many, file a claim for you and bill you later.

We have BCBS, and we live in Northern Virginia. My LLMD is out-of-network, and I have to pay for each visit upfront and file a claim myself. What a pain!

I just received the first check from BCBS for the first 3 visits I had filed for together (it took more than a month since I sent my claim.)

I got a little less than 1/2 of what I had paid, although I did start wondering if they would ever pay me back.

Luckily all other doctors of mine are in-network.

However, when we have five people in the family and everybody (mostly me and my hubby) needs prescriptions and various tests (even surgery) done, it just adds up.

shizuko

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geniveve
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here in texas, bcbs will not pay for out of pocket. i have a federal plan and they only pay about 15-20 percent out of pocket and i have to pay the rest. i don't dare go to out of network, i pay through the yingyang..................
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lou
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This has happened to other lyme docs over the past several years. The ins co intends to discourage use of these docs. Make it too expensive.
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5dana8
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mimi

I am so upset to hear this news for you [Frown]

I have also heard that compounding pharms are cheaper.

sending you a pm .

hang in there my NC friend [group hug]

--------------------
5dana8

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ConnieMc
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One thing to consider as well - MOST LLMDs do not take insurance at all. Dr. J is one of the few who still does. Perhaps this sort of thing has happened to the other LLMDs and that is why they usually require payment up front.

I wouldn't be surprised if this happened with Dr. J. He is spending huge bucks and time fighting these insurance companies.

I also think patients should think about a class action suit to sue these crooks.

They were hoping Dr. J would go down at the hearing, and that did not happen. Now, they are looking for other ways to keep from paying.

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ConnieMc
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Anyone want to investigate the possibility of filing a class action suit against NC BCBS? I hear from a good source that the NC Department of Insurance isn't even acting on the hundreds of complaints they have received from patients about BCBS not paying claims.

For anyone interested in pursuing this, let me know. I would like to first pull together some ideas. The ideal situation would be to get an atty who is willing to take this on a contingency basis, but not sure how something like that could be structured. Money up front might be a problem. Many lymies are broke and so am I. But there is nothing really to WIN, other than the benefits. Would be difficult to figure this all out.

Anyone know an attorney with HIV/AIDS or Lyme who would work on something like this?

Grasping at straws here, but if this can be organized, I think it is worth pursuing.

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northstar
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Perhaps the person at the Raleigh paper might be interested?

About the other BCBS complaints: these are not all lyme patients? Then that would make the story line a different scenario, with the focus on the State Insurance Board as sluggish, nonresponsive to many complaints.

This wont cost a lawyer, yet.

N.

p.s and how are they punishing the ignorant ones who could not diagnose? Stupidity pays?

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lou
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What you are looking for is someone prominent who does pro bono work. I believe there is a Harvard website which lists attorneys who do this as part of a project, whose name I don't recall. These include such people as the famous tobacco lawyers, the ones who won against the tobacco companies. But I don't think this should be restricted to NC.

In fact, one of them did a very successful rackeeteering lawsuit against several health insurance companies, which resulted in big fines.

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ConnieMc
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quote:
Originally posted by lou:
What you are looking for is someone prominent who does pro bono work. I believe there is a Harvard website which lists attorneys who do this as part of a project, whose name I don't recall. These include such people as the famous tobacco lawyers, the ones who won against the tobacco companies. But I don't think this should be restricted to NC.

In fact, one of them did a very successful rackeeteering lawsuit against several health insurance companies, which resulted in big fines.

Lou, I was thinking we will probably have to go out of state to find someone worth a darn. I know BCBS has many connections around the state, and as a result, many would not touch this with a ten-foot pole.

Will do a search to see what I can find.

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pab
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I hope everyone can find another LLMD. Things like this can be at times harder than the illness itself.

Our LLMD is out-of-network (not Dr. J). Our insurance says the fair & reasonable charge for his area is $158. Our out-of-network coverage is 70%.

Our LLMD charges $240 per visit - which is worth it to me. We pay up front and then submit the claims. We pay $960 per visit for 4 of us and we are reimbursed $442.

--------------------
Peggy

~ ~ Hope is a powerful medicine. ~ ~

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Tincup
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Why not send to your doctor and insurance companies the following information. Tell them you are following the ILADS guidelines for the diagnosis and treatment of Lyme disease, as they are the ONLY valid ones.

```````````````````````````````````````````````

Dear Insurance Company,

The Infectious Disease Society of America (IDSA) 'Practice guidelines for the treatment of Lyme disease' (2000) have officially been withdrawn.

http://www.guideline.gov/browse/gawithdrawn.aspx?st=I

Withdrawn NGC Summaries

Infectious Diseases Society of America

Practice guidelines for the treatment of Lyme disease. (NGC-1898)

Wormser GP, Nadelman RB, Dattwyler RJ, Dennis DT, Shapiro ED, Steere AC, Rush TJ, Rahn DW, Coyle PK, Persing DH, Fish D, Luft BJ. Practice guidelines for the treatment of Lyme disease. Clin Infect Dis 2000 Jul;31(Suppl 1):1-14. [99 references]

```````````````````````````````````````````````

Lyme disease patients should be afforded nothing less than the highest quality of health care services and should have access to the most up-to-date standards of care available.

The International Lyme and Associated Disease Society (ILADS) "Evidence-based guidelines for the management of Lyme disease" are up-to-date (2004), peer-reviewed, diagnostic and treatment guidelines which have been approved for use by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality (AHRQ), the American Medical Association, the America's Health Insurance Plans [AHIP], the International Lyme and Associated Diseases Society (ILADS), the Lyme Disease Association (LDA) and many world wide organizations.

The ILADS guidelines, therefore, are be THE standard of care. Promoting or allowing the use of guidelines that have been proven to be unsuccessful for many people over the years, which are admittedly outdated and have officially been withdrawn, for ANY reason, is simply not acceptable.

Sincerely,

-----------------------------------

--------------------
www.TreatTheBite.com
www.DrJonesKids.org
www.MarylandLyme.org
www.LymeDoc.org

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lymednva
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This a shot in the dark, but what about John Edwards? He's from NC and that's how he made his money.

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

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lymex5&counting
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This is worth a try to those affected. And on BCBS PPO.

Call the MSA dept and ask if you can apply for a PPO waiver?

If you live a certain # of miles (30 I think)

from the clinic. And since he is an ID doc that

is a specialty. And since you have lyme. If your

plan allows you may qualify for in network

coverage for an out of network Dr.

My kids see Dr J (CT) for about $21.80 a visit

since they have PPO waivers on file. They usually

last 6 months for Drs. and 3 months for labs.

All 6 of us have them for IGeneX. That way it is

covered 100%.

Sorry some of you are going thru this and poor Dr J.

Otherwise as far as I am concerned this is really [cussing] [cussing] [cussing] !!!!!

Lyme x 9

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bettyg
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Check your BCBS booklet for appealing; it gives very specific instructions in our IOWA booklet.

Sorry to read about this new development! Bettyg

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ksparks
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I am meeting with a "friend of a friend" who is an attorney to talk about my about my case. I will let you all know what she says and I will fill her in on all of this mess. I had BCBS until this month and know what you all are going through. We can file a complaint with the NC Dept of insurance, but i am not sure what that would do.

I think Dr. J is going to have to fight this out with BCBS because he was a contracted provider and they are the ones who broke the contract.

I will keep you posted. I probably won't meet with the attorney for a few weeks because she will be out of town. She is lyme friendly and likes to stick it to the insurance companies.

keep your chins up-

Kristen

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mimi
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Hey guys I have been on the phone all day [Frown] With

the help of several of you I have located a

pharmacy that is willing to help. I will find

out tomorrow if Dr. J's office will allow me to

get my drugs from another pharmacy and them do

the care. I have BCBS of SC I have always been

out of network. But because of BCBS of NC


pulling out they will not file any BCBS insurance

and we will all have to pay up front for

everything. [Frown] So if I can help fight to get

them back please let me know
Take care
mimi

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lymednva
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I asked my LLMD about this at my appointment today and he said that because of the status change of Dr. J's license it would be cause for BCBS to make him out of network.

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

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AP
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quote:
Originally posted by lymednva:
I asked my LLMD about this at my appointment today and he said that because of the status change of Dr. J's license it would be cause for BCBS to make him out of network.

Yeah, it sucks, but from a legal stance, BCBS had every right to pull out of their contract... In their eyes, and in the eyes of the folks with big wallets, desk jobs, and perfect health, Dr. J is the one who pulled out of the contract when he supposedly (and I say supposedly because he's my LLMD, and I have a ton of respect for him and his practice) screwed up.

--------------------
Sometimes when I say Oh, Im fine I want someone to look me in the eyes & say tell the truth

Myspace: http://tinyurl.com/5p64ed

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5dana8
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This really stinks. [cussing]

I am so mad right now I could lift the house if I wasn't so tired. [Frown]

[ 12. July 2006, 04:10 PM: Message edited by: 5dana8 ]

--------------------
5dana8

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