BCBS Of Florida Only Sends Reader 12% Of What They Owe Him

The good news is that Ander has gotten checks from Blue Cross Blue Shield of Florida. The bad news is that they’re $6265 off the mark of what he should be getting. He has worked with BCBS and the Florida Insurance Commissioner, but neither has been able to successfully make BCBS’ check-sending system match the reality of their financial obligations to Ander…

I’m a long time reader, but I’ve never posted anything. I need help, I’m at the end of my wits. Here’s the down-low:

December 10th, 2007 I had a bi-lateral arthroplasty on my jaw for TMJ. This was medically necessary as proven by an MRI and approved beforehand by Blue Cross & Blue Shield of FL. The grand total came to $7125, and since the doctor was a non-participating provider I had to pay in full up front and the doctor’s office would file with Blue Cross & Blue Shield of FL for me to get reimbursed.

A couple weeks later I called up the automated claims line to check the status and it said it was denied, and the human rep I was transferred to said it was for lack of information on the claim. Come to find out, the doctor’s office had submitted it with the office provider number, not the doctor’s number which BC/BS required. It was immediately refilled with the correct number. I called to check on it a couple weeks later to find it was denied AGAIN for the same reason. The info was faxed over again and this time I spoke to Felicia and got a confirmation number that they did actually get the info. Two weeks later it’s the same deal. They never got the info.

Now I’m getting a little frustrated. I called the Insurance Commissioner on 2-19-08 and was working with Debbie. She spoke to the insurance lady at the doctor’s office and we sent Debbie all the information we had: the original claim, the EOBs, everything. Debby sent BC/BS a nice letter stating they had 30 days to remedy the claim. About a month later I got a check in the mail and a letter from Debby saying the claim was resolved! Too bad it was $430 for a claim that was less than half of what it should be. I called back Debby and told her NO, it was NOT resolved. She said there was nothing else she could do and I should speak with my local insurance rep at my work who could file a grievance and appeal.

I decided to call up customer service one more time on 5-5-08. This time I spoke with Stephanie who was very helpful. I told her the whole deal and explained that the claim should be filed with the $7125 amount, not $3100 for a claim that I or the doctor’s office still don’t know what is for. She then did reprocess the claim with the correct amount and correct provider number and furnished me with a reference number. Thursday, 5-15-08, I got another $430 check for the aforementioned mysterious claim.

Today, 5-20-08, I called a lawyer to set up a consultation. I’d really rather just get my claim paid than have to go through all this legal nonsense. Please Consumerist, do you or the venerable hive-mind have any tips, or can find me some addresses I can drop a formidable EECB on? Thanks for any help.

We’ll help you get that EECB started. It looks like the email address format is lastname.firsname@bcbsfl.com, or sometimes just lastname@bcbsfl.com.

Here are some company executives:

Robert I. Lufrano Chairman and CEO
R. Chris Doerr EVP, Chief Administrative Officer, and CFO
Fred Ryder SVP, Corporate Development and Strategy
George W. Foyo [President, Operations, South Florida]
Tony Jenkins [President, Market]
Daryl Veach [Chief Actuary & Vice President]
Jeannette W. Ekh [Chief Information Officer]

How did we figure this out?

1. We googled Blue Cross Blue Shield of Florida.
2. The website is bcbsfl.com
3. We googled *@bcbsfl.com
4. Glancing through several pages of results we saw an email address or two that gave us the company format.
5. BCBSFL’s Google Finance page had some of their high level execs.
6. Googling “Blue Cross Blue Shield Of Florida” gave us some more execs.
7. Now just combine and you’ll have yourself a functional executive email carpet bomb.

(Photo: Getty)

Comments

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  1. wickedpixel says:

    I see this ending in BC/BS sending Ander to collections for $860.

  2. Trai_Dep says:

    Phew! Thank the GODS we don’t have single-payer. Otherwise it’d be 30% cheaper and the poor guy would have a bill of… Oh, wait. No bill.
    Well, thank the GODS for insurance companies, since they’re certainly earning their 30% overhead fees!

  3. Crymson_77 says:

    @wickedpixel: Sadly, I think we all do…

  4. graymulligan says:

    @wickedpixel:

    I’m going to hell because I laughed atthat, aren’t I?

  5. Roy Hobbs says:

    @Trai_Dep: Yes, because government agencies have proven themselves to be so much more efficient than private entities that actually have a profit motive.

    /not against universal health care, so don’t start
    /am against blindly believing that government agencies are the right solution to all of this

  6. sdusty143 says:

    Im curious to see an actual EOB and see what the allowed amount was for. Depending on his contract, BCBSF will ONLY reimburse a certain percentage of the ALLOWED amount. Not the full charge. I dont understand why anyone would see a non participating provider on purpose. I would suggest he check out his benefit package. If this was a procedure its very likely the allowed amount is only around $1750.

  7. hills says:

    Been there, done that. Appeal – happens all the time.
    I suggest you find out what the maximum allowable amount is for this procedure at a non-participating provider. Unfortunately, it may only be $860 ($430 + $430), in which case you’re on the hook for the remainder. If it’s more than that, BCBS needs to pay up. Good luck!

  8. vp_bsu says:

    Try a claims professional. Check out this site and find someone near you to talk to. These people are experts in dealing with insurance companies and providers to make sure all claims are filed and paid properly.

  9. vp_bsu says:
  10. Go back to the insurance commissioner’s office.

    In my experience the state agencies can get the insurance company quite motivated to pay the bill.

    Also, depending upon your state, you may want to contact your governor’s office. My governor has a hot line to coordinate state agency responses to citizen problems….. I had a workman’s comp claim that was not being paid, one call and it got paid really fast.

  11. fjordtjie says:

    BCBS was horrible for that with me. it always took about 10 calls to sort out all the crap. finally switched providers. Good luck!

  12. ConsumerAdvocacy1010 says:

    I say stick with the lawyer and go after them for all the money you can. That’ll teach ‘em… for a few days.

  13. Trai_Dep says:

    @Roy Hobbs: Medicare has overhead under 3%, while private insurance companies have overhead OVER 30%, while providing the service detailed in this story. They’re an unnecessary layer adding nothing but profit to Wall Street and CEOs (sucked from the sick and us people working for a living).
    If gov’t run health care is so awful, why do your Republican senators, representatives and the President cling to it for their needs so diligently?

  14. CRNewsom says:

    If you want single-payer plans and think for a second that the government won’t dole out the administration of it to companies with names like Kaiser Permenante, United Healthcare, Blue Cross/Blue Shield, you aren’t seeing the big picture. Medicare’s first line of defense (claims processing) is done by the insurance carriers, not the government.

    A single payer system will look very similar to the current situation, but government run and underfunded.

  15. GaelicVyk says:

    Hey everyone, Ander here.

    Consumerist, you guys rock for posting this.

    Wickedpixel, I haven’t deposited the two checks for $430.

    sdusty143, the EOBs actually allow for over $5000 to be paid back to me.
    Since this has been going on for over 6 months they owe me interest too. That probably won’t come to $7k, but I never said it would.

    This is the insurance plan I have through work. I have contacted the appeals department and have started that up too. I’ll keep you updated with whatever happens.

  16. Hambriq says:

    @Trai_Dep:

    And Medicare is a bankrupt system. And it’s forcing independent doctors, pharmacies and other health care providers to stop accepting it because its reimbursement rates are so low and intermittent. And, this bears repeating: it is a bankrupt system.

    This isn’t a political issue, this isn’t a “right vs. left” thing. It’s a “How can we offer the highest level of health care to all Americans?” thing. Obviously our current system is not working, but only the naive think that a single-payer system is a magic bullet.

  17. BigElectricCat says:

    @Hambriq: “And Medicare is a bankrupt system. And it’s forcing independent doctors, pharmacies and other health care providers to stop accepting it because its reimbursement rates are so low and intermittent. And, this bears repeating: it is a bankrupt system.”

    Uh, no. It’s not. I deal with it on pretty much a weekly basis (my mother is disabled & retired), and it looks to me like you don’t know what you’re talking about.

    What personal experience do you have with the Medicare system, exactly?

  18. Bellatrixie says:

    I work in a doctor’s office doing the billing; however, not in Florida where the rules may be different.

    Here, because we are a provider for BCBS, we are not allowed to demand payment up front for services. It seems like if they asked for money up front, then perhaps they are not a “Preferred Provider” with the local PPO or not on the HMO option. This may be the reason for the discrepancy in the billed amount. You see, we have a flat rate that we bill, say $150 for an office visit. Because we are a Preferred Provider with BCBS, our agreement with them means that BCBS patients only have to pay at the “Allowed Amount” of the negotiated fee schedule which figures out to be about 54% percent of charges or about $80. That number only applies to BCBS patients though. When an Out-of-Network patient is seen, they are responsible for any amount over what their insurance company determines is “reasonable and customary”. It may be that BCBS determined that $3100 was their fee schedule amount for this surgery and they are only paying the patient a percentage after deductibles/copay/coinsurance; hence the low payment amount.

    I know it’s bloody confusing, but I deal with it everyday.

  19. Hambriq says:

    @BigElectricCat:

    Let’s see. I work at a pharmacy. I have worked at several pharmacies in the past, independent
    and retail. I have seen first-hand the financial impact of Medicare and Medicaid’s low rate of reimbursement. I have seen small town pharmacies shut down and replaced by chain pharmacies that service the entire town because that is the only way to achieve the economies of scale necessary to keep their business afloat after Medicare’s low rate of reimbursement.

    Of course things look good to you. You are on the patient end of things. When you are on the other side of the counter, the situation is not as rosy. We are already feeling the effects of Medicare’s dire financial straits. And when the baby boomers start to retire and more people are taking out of the system than are putting into the system, you will start feeling the effects on the patient’s side.

  20. Hambriq says:

    Also maybe I should clarify, because BEC’s post does highlight the massive disconnect between the patient and the provider. Medicare’s reimbursement rate doesn’t refer to how it pays the patients. It refers to how it pays the provider. Medicare and Medicaid are notorious for providing abysmally low (and late) reimbursement rates.

  21. CRNewsom says:

    @Hambriq: What do you mean when the boomers retire? It’s happening right now! Social Security, Medicare, Medicaid, VA Hospitals, etc. are all hemorrhaging money. I don’t see how any one of them is sustainable in the long run without major reforms. This may mean pushing back Social Security to 70 years of age, but that would only give it a few more years, at most.

  22. ConsumerAdvocacy1010 says:

    @Hambriq: Same with hospitals. I’ve witnessed hospital staff members doing their best to cope with the insurance companies, even when procedures (standard procedures like those for baby delievery) are routinely denied. In fact, our hospital was recently fined by the government for not complying with the insurance companies and not getting re-imbursed.

    Excuse me? THEY (insurance companies won’t pay) and time and time again they never follow up as to why the claims were denied. The people working there have no idea how to do a darn thing and they keep making mistakes and improperly filing things…. Then the Government has the presence of mind to fine…..US?

  23. snidelywhiplash says:

    @CRNewsom: Of course, they could just implement this crazy-assed idea I’ve heard of and raise the cap on on FICA withholding. I know, it’s crazy talk…

  24. Hambriq says:

    @snidelywhiplash:

    So we fix a broken system by throwing more money at it? When was the last time that worked?

  25. GaelicVyk says:

    @Bellatrixie: The doctor is a non-participating provider, that’s why I had to pay upfront.

    As for the EOBs being different, I DO have 3 or 4 EOBs with the correct $7125 amount saying they allow $5100 or so, and have denied payment for lack of information which is the wrong provider number (that has been provided to them 4 times.)

    The other EOBs with the $3400 amount that they have paid $430 on has listed one arthroplasty at $375 which they actually were $3750 each side (it came out less because I got a cash discount), so that looks like a misplaced decimal along with completely missing one whole side of the surgery. Also listed is something called a tenotomy for $3000 or so, which the doctor said was basically a scissor clamp and doesn’t cost near that much. So yea, the whole deal is a mess.

  26. BigElectricCat says:

    @Hambriq: “Let’s see. I work at a pharmacy. I have worked at several pharmacies in the past, independent and retail.”

    Excellent. Then I’m not speaking to someone who is without a clue.

    @Hambriq: “I have seen first-hand the financial impact of Medicare and Medicaid’s low rate of reimbursement. I have seen small town pharmacies shut down and replaced by chain pharmacies that service the entire town because that is the only way to achieve the economies of scale necessary to keep their business afloat after Medicare’s low rate of reimbursement.”

    Quite frankly, I think you’re full of bulldada on this point. How, exactly, can you plausibly claim that Medicare/Medicaid ran small-town pharmacies out of business when M/M’s been in operation since the 1960s? Furthermore, how do you know that it’s not simply the scale econs of the big-box pharma chains that the smaller, local pharmacies fell victim to?

    I think your economic analysis is quite lacking, but I’m open to hearing what else you have to say on the topic.

    @Hambriq: “Of course things look good to you. You are on the patient end of things.”

    I guarantee you that things don’t “look good” to me. I simply took issue with your assertion that “Medicare is a bankrupt system.” Don’t try to pull your argument out of a crack by putting other words in my mouth. Medicare has a boatload of problems, to be sure. But bankruptcy is not one of them.

    @Hambriq: “When you are on the other side of the counter, the situation is not as rosy. We are already feeling the effects of Medicare’s dire financial straits.”

    How dire, exactly? Verifiable specifics, please.

    @Hambriq: “And when the baby boomers start to retire and more people are taking out of the system than are putting into the system, you will start feeling the effects on the patient’s side.”

    Just to be clear, I am a boomer, and not so terribly far from retirement myself.

    @Hambriq: “Also maybe I should clarify, because BEC’s post does highlight the massive disconnect between the patient and the provider. Medicare’s reimbursement rate doesn’t refer to how it pays the patients. It refers to how it pays the provider. Medicare and Medicaid are notorious for providing abysmally low (and late) reimbursement rates.”

    And some providers are notorious for boosting the crap out of their costs and then failing to provide itemized billing to patients. I’m presently fighting with a hospital over a seven-year-old bill for my mother, during which neither she nor I signed a single document. The hospital refuses to provide an itemized bill of products and services provided, and I am reluctant to hand over five figures’ worth of cash without at least a listing of where the money went. The hospital’s been telling me since 2001 that they can’t give me that information (despite the fact that they have a verified POA on file between myself and my mother) and are threatening to file suit.

    Actually, I kind of want them to sue at this point, because in the discovery phase, our attorney ought to be able to get the fuggin’ itemized bill out of them.

    I’m sorry, Hambriq. I don’t have a lot of sympathy for health care providers who crap about Medicare reimbursement when there are rapacious, poop-flinging monkeys in your industry like the ones I’m fighting at the hospital that treated my mother. Frankly, I think that our mutual experiences only serve to underline the need for a single-payer healthcare system in our country. Under such a system, your pharmacy would get paid without a bunch of hassle, and my mom wouldn’t get gouged and threatened by primates in business suits.

  27. Hambriq says:

    I’m not saying our current system is working. I’m saying right now, Medicare is set to be bankrupt by 2019. According to the Medicare Trustees.

    Quite frankly, I think you’re full of bulldada on this point. How, exactly, can you plausibly claim that Medicare/Medicaid ran small-town pharmacies out of business when M/M’s been in operation since the 1960s.

    Because we’re spending roughly 74 times the amount of money on health care in 2008 (2 trillion) than we were in 1960 (27.1 billion). The problem we are facing is that health care spending is rising exponentially higher than any amount of payment being made into the system. Until we find a way to drive down costs, we are just going to see more problems on both ends. Public systems like Medicare will be woefully underfunded and will eventually have to shut down or delay the inevitable by raising taxes. And private systems will be forced to continue increasing their efficiency… or in laymen’s terms, screwing the consumer.