Hubby just discovered this change to policy recently. Sometime late last fall BCBS decided that in some cases babesia can be a life-threatening illness. Because of this they will pay doctor office visit claims as in network even for out of network doctors.
But of course there is a catch to this -- in network claims have to specify the number one complaint. Most LLMD's list mutiple diagnosis codes. Hubby's LLMD has a form where the most common primary diagnoses are listed in alphabetical order. So when the claim is filed the 1st item listed is considered the primary diagnosis.
For one recent visit the first item checked was arthralgia -- other codes included babesia and bartonella and lyme etc. This claim was paid as out of network.
The next claim also had babesia and bartonella and lyme but arthralgia was not listed -- I think fatigue might have been one of the other codes on that visit. But this claim was paid as in network since babesia was the 1st code checked on the alphabetical list.
It may not sound like this would make much difference since for hubby out of network claims are paid at 70% and in network at 80% of reasonable and customary allowances. But it actually works out to about $100 difference per visit because he has already met the annual deductible on in network but not for out of network. And also the maximum out of pocket amount is twice as much for out of network as in network so it will help out later in the year as well.
Bea Seibert
Posted by Haley (Member # 22008) on :
I didn't realize that the type of illness could change the status of out of network to in network.
Interesting. I just keep paying those bills. I probably wouldn't even notice that if it showed up on my statement.