Wednesday, July 24, 2024

Blue Cross

Bernie Veldman

Several months ago, I posted a request for input into everyone’s experience with BC/BS. I posted the responses, but needless to say they were overwhelmingly negative.

The dilemma is:

The in-network fee schedule is far below even Medicaid pricing. (we would even show a substantial loss by the time that we figure professional, technician and administrative time into the equation) As an in-network provider, we are forced to call and spend hours on hold not just once, but many times in order to have them send the check to the patient who invariable buys a television or stereo system with it, but then does not have the financial resources to pay us for a service that we provided.

As an out-of-network provider, we are actually paid at a higher allowed amount. We have the option of writing off a portion of the patient’s out-of-pocket expense, so that they are not penalized for going to one of the evil “out-of-network” providers. BC/BS however, will then send the check to the patient, usually within two weeks and it would be our responsibility to collect from the patient/client. Even writing off a portion of the patients out-of-pocket, we come out far ahead of in-network coverage.

I have read many discussions through this group regarding the legalities of billing issues. Many have said that it is “illegal” to bill for these services until the orthosis is actually delivered. I would like to read this “law” or directive or guideline or whatever. Where can I find more information about this subject.

It should be a feasible scenario to bill out of network at the time of casting / measuring. Then by the time that we are ready to schedule a fitting, the patient should have received a check from BC/BS. They would be required to turn over that check at the time of delivery. If, for some reason there were to be a problem at the fitting, or the patient/client did not return for a fitting, we could then make the appropriate adjustment with BC/BS and let them collect the money from their client. This would mean many, many hours saved on the telephone. It would also put some of the responsibility back into the hands of the patient/client.

We have studied our contract with BC/BS extensively, and there is no mention of the date-of-service being required on the date-of-delivery the way that the Medicare manual states. If I am in error here, please let me know. I am at my wits end with the entire Anthem BC/BS network, but I do not like to turn away patients/clients that our referral base sends to me.

Thanks in advance for the input. I will post responses without names.

Bernie T. Veldman
BOC Orthotist
[email protected]


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