Welcome Guest! To enable all features please Login or Register.

Notification

Icon
Error

Financial Discussion

It is always wise to have a secure financial foundation. Here is a place to ask questions, exchange ideas and share information on how to make the most of your money.


To read today's top news stories on federal employee related news visit FederalDaily.com.
2 Pages12>
Options
Go to last post Go to first unread
GSBS  
#1 Posted : Friday, April 06, 2012 7:24:34 AM(UTC)
GSBS

Rank: Senior Member

Groups: Registered
Joined: 10/9/2011(UTC)
Posts: 1,678

Thanks: 1 times
Was thanked: 2 time(s) in 2 post(s)
It just gets worse yearly. I have a Standard Option Blue Cross Blue Shield plan, considered to be one of the top plans offered by the Government.  First of all where is the buying power of the Government in any of plans offered? $7000 a year for a single plan?  So anyway I smashed my head, went to my local "In Network Hospital" where the cost was zero for an "Injury". Except the Doctor is a contractor, which I already knew. I thought ER laws regarding these non participating ER Doctors in a participating hospital had changed in 2010.  To make a long story short I am responsible for all charges over the BCBS allowable charge. Then I am told they actually should have paid me less, but the contract agrees to match the MEDICARE rate.  What, I have full Insurance paid at the Medicare Rate?  There are Doctors that won't touch a Medicare patient, and Blue Cross Blue Shield feels the Medicare rate is adequate compensation for its paying non Medicare customers who have no choice where they are taken?  This happens nationwide. Our benefits are sub standard. I've had better.
OUtside  
#2 Posted : Friday, April 06, 2012 8:39:01 AM(UTC)
OUtside

Rank: Senior Member

Groups: Registered
Joined: 8/19/2008(UTC)
Posts: 684

Was thanked: 3 time(s) in 3 post(s)

If you are age 65+ (and why would you be talking re: Medicare otherwise?), the most the dr can charge you is 115% of the Medicare rate. Since the Medicare rate is usually low anyway, 115% isn’t that much higher, so after BC pays, you should not have a huge out of pocket to pay.

And for dr’s who won’t touch a Medicare patient, they can touch them in an emergency (but they can only charge 115% of the Medicare rate if they do).

How about posting some specific numbers in dollars and cents so we can get a clearer picture just for information?

GSBS  
#3 Posted : Friday, April 06, 2012 9:33:18 AM(UTC)
GSBS

Rank: Senior Member

Groups: Registered
Joined: 10/9/2011(UTC)
Posts: 1,678

Thanks: 1 times
Was thanked: 2 time(s) in 2 post(s)
Because this was an Injury not an Illness, the Facility Charge was no cost, including the Cat Scan, X Ray's, and Blood work. The ER physician charge was $1400. Blue Shield paid $555, tied to the Medicare rate and I am responsible for the rest. About Medicare, I don't have that. I have BCBS FEP.  If I would have driven to the next participating hospital 10 miles away it would have been free as they maintain a staff of their own Physicians, and are an In Network provider. I can go anywhere for my health care, and sure I know you pay more if you go out of network. I could have sworn there was a federal law at the end of 2010 that changed this common practice. Again to hear that my private Insurer (BCBS)  paid compensation to a non participating provider tied to the Medicare rate is incredible.  
Kathi52  
#4 Posted : Friday, April 06, 2012 9:52:53 AM(UTC)
Kathi52

Rank: Senior Member

Groups: Registered
Joined: 1/4/2009(UTC)
Posts: 773

GSBS, go to Fepblue.org and/or look at your 2012 plan. It spells it all out. Read carefully the warning about non-participating providers and LOCAL plans. So, in actuality there is nothing wrong with our plans. The problem was with the non-participating contractor doc. And the bit about the Medicare rate (it's in there also) is correct. Sorry about your injury; should have said that first.
GSBS  
#5 Posted : Friday, April 06, 2012 10:26:14 AM(UTC)
GSBS

Rank: Senior Member

Groups: Registered
Joined: 10/9/2011(UTC)
Posts: 1,678

Thanks: 1 times
Was thanked: 2 time(s) in 2 post(s)
Thank you Kathi!  Your information is excellent, it was exactly what I was told by the BS rep today. Most people in my town get free State, County, and Federal care. I don't and am years to Medicare.  Yes I know what happens seeing any out of network provider who is working out of preferred provider facility.  I was almost sure about these new federal rules for ER visits. If only there was the perfect medical plan for the money spent on our federal policies. So now I owe $1400 because I smashed my head somehow. If I could have found out what happened it would have been worth any price!
dhacker56  
#6 Posted : Friday, April 06, 2012 10:29:08 AM(UTC)
dhacker56

Rank: Senior Member

Groups: Registered
Joined: 12/9/2008(UTC)
Posts: 6,380

I had that happen once to me when the ER plainly stated that they were PPO.  when I got the bill from the ER doctor I took it to the Hospital and complained and the hospital took care of it.

GSBS  
#7 Posted : Friday, April 06, 2012 11:36:55 AM(UTC)
GSBS

Rank: Senior Member

Groups: Registered
Joined: 10/9/2011(UTC)
Posts: 1,678

Thanks: 1 times
Was thanked: 2 time(s) in 2 post(s)
dhacker56 wrote:
I had that happen once to me when the ER plainly stated that they were PPO.  when I got the bill from the ER doctor I took it to the Hospital and complained and the hospital took care of it.
It happens all the time. It could be the anesthesiologist, it could be the radiologist, sometimes an assistant surgeon.  You do your diligence and always ask are you a preferred or participating provider? However some of our professionals we never see, and these contractors can jack up the prices $1000 or more. My Hospital and many hospitals across America have nothing to do with ER Doctors & contractors.  Billing groups like Emcare, a huge one in PA. just says how sorry they are and ask how would you like to pay?  On a previous $1100 ER visit they wouldn't accept a $750 Blue Cross check so I just spent it! I'm on $10 payments. It is horrible to know BCBS based at least this fee on Medicare. How embarrassing. I don't even have MEDICARE.   GSBS2012-04-06 19:52:07
skunker  
#8 Posted : Friday, April 06, 2012 9:08:43 PM(UTC)
skunker

Rank: Senior Member

Groups: Registered
Joined: 12/2/2009(UTC)
Posts: 211

I had something like this happen to me by going to a dental clinic that was in-network, but turned out the dentist was not! When I got the bill, I simply sent an email to BCBS stating that I specifically used their provider cataloge to locate an in-provider clinic and that's why I chose this clinic. I told them that if I knew they were not in-network I would not have gone to them! BCBS wrote back stating they understand and therefore sent me a check for reimbursement. 
GSBS  
#9 Posted : Saturday, April 07, 2012 1:21:03 AM(UTC)
GSBS

Rank: Senior Member

Groups: Registered
Joined: 10/9/2011(UTC)
Posts: 1,678

Thanks: 1 times
Was thanked: 2 time(s) in 2 post(s)
While we might have different plans or suppliments, BLUE CROSS BLUE SHIELD does not understand or forgive you financially if you go to a provider that is no longer in network. Those books are printed up to a year in advance. They don't care what we think as it is our obligation to ask the provider or the office if they are still a provider. The benefit level is negotiated by OPM, and they pay strictly according to their contract. Even at the ER for those not brought in unconscious to read is a sign that says the Doctor is a separate provider, and you are responsible for all charges. I go to a BCBS Dentist too, and even in Network I am responsible for all charges over the $16 cleaning, $6 filling, or $3  X Ray they pay?  GSBS2012-04-07 09:48:49
OUtside  
#10 Posted : Saturday, April 07, 2012 1:51:29 AM(UTC)
OUtside

Rank: Senior Member

Groups: Registered
Joined: 8/19/2008(UTC)
Posts: 684

Was thanked: 3 time(s) in 3 post(s)

If you are of Medicare age (65+), where the Medicare rate would be used, then the Medicare rate likely would be a low rate, sometimes quite low, compared to going rates.

However, if you are younger than Medicare age, reading page 132 of BC brochure suggests a higher rate and geared to the specific geographic area where the service was performed. For example, the brochure says the allowance would be the greater of the Medicare rate or 100% of the usual and customary rate amount for the service. In other words, if the Medicare rate is used, it is greater than 100% of the usual and customary rate. This suggests the rate in this instance is not an especially low rate.

The brochure suggests contacting the local plan for more information. I think if I had this problem, I would do this while considering asking the provider to negotiate the charge somewhere between the allowance as given by BC (apparently not an especially low rate) vs. his/her bill which is so much higher.

Fed1969  
#11 Posted : Saturday, April 07, 2012 2:25:06 AM(UTC)
Fed1969

Rank: Senior Member

Groups: Registered
Joined: 10/28/2010(UTC)
Posts: 3,333

This is an example of problems that happen when one does not have Medicare.
GSBS  
#12 Posted : Saturday, April 07, 2012 2:33:04 AM(UTC)
GSBS

Rank: Senior Member

Groups: Registered
Joined: 10/9/2011(UTC)
Posts: 1,678

Thanks: 1 times
Was thanked: 2 time(s) in 2 post(s)
OUtside wrote:

If you are of Medicare age (65+), where the Medicare rate would be used, then the Medicare rate likely would be a low rate, sometimes quite low, compared to going rates.

However, if you are younger than Medicare age, reading page 132 of BC brochure suggests a higher rate and geared to the specific geographic area where the service was performed. For example, the brochure says the allowance would be the greater of the Medicare rate or 100% of the usual and customary rate amount for the service. In other words, if the Medicare rate is used, it is greater than 100% of the usual and customary rate. This suggests the rate in this instance is not an especially low rate.

The brochure suggests contacting the local plan for more information. I think if I had this problem, I would do this while considering asking the provider to negotiate the charge somewhere between the allowance as given by BC (apparently not an especially low rate) vs. his/her bill which is so much higher.

Yes the contract has the answer and its as clear as can be! I am 53 and do not get medicare. Under the "Affordable Care Act" I thought this was addressed in 2010. Nope, existing Plans were EXCLUDED, Grandfathered OUT?  I live in a small town, just trying to support the local participating hospital. There is no negotiation with this billing group "Emcare". I found that out two years ago, and I also found out how big they were.  Many great complaints on Google. In any case BCBS sent me the cash and I am not going to fork over $1500 this time. Bottom line the new regulations I found will not help me in the least!
 
  • Access to out-of-network emergency room services: In the past, some health plans would limit payment for emergency room services provided outside of a plan’s preselected network of emergency health care providers. Or they would require you to get your plan’s prior approval for emergency care at hospitals outside its networks. This could mean financial hardship if you get sick or injured while away from home. The new rules prevent health plans from requiring higher copayments or co-insurance for out-of-network emergency room services. The new rules also prohibit health plans from requiring you to get prior approval before seeking emergency room services from a provider or hospital outside your plan’s network.

    Some Important Details

    • These rules apply to all group health plans and individual health insurance policies created or issued after March 23, 2010.
    • These rules do not apply to “grandfathered health plans.”
    • If your health plan or health insurance policy was created or issued after March 23, 2010, your plan will be affected as soon as it begins a new “plan year” or “policy year” on or after September 23, 2010.
    • Please note that you still may be responsible for the difference between the amount billed by the provider for out-of-network emergency room services and the amount paid by your health plan.

    http://www.healthcare.gov/law/features/rights/doctor-choice/index.html

  • GSBS2012-04-07 11:15:30
    OUtside  
    #13 Posted : Saturday, April 07, 2012 4:00:35 AM(UTC)
    OUtside

    Rank: Senior Member

    Groups: Registered
    Joined: 8/19/2008(UTC)
    Posts: 684

    Was thanked: 3 time(s) in 3 post(s)

    That is interesting, indeed.

    But I think it gets more interesting, too.

    BC page 132 says the rate for emergency services will be the greatest of the Medicare rate, or 100% of the UCR, or based on compliance with the Affordable Care Act.

    Good for you for recollecting this change from 2 years ago and doing the research pertaining to the grandfather clause. But is the grandfather clause applicable with respect to page 132 of current brochure?

    penelope1440  
    #14 Posted : Saturday, April 07, 2012 4:44:58 AM(UTC)
    penelope1440

    Rank: Senior Member

    Groups: Registered
    Joined: 11/11/2008(UTC)
    Posts: 697


    I am in a similar argument with BC/BS now over an emergency room visit last year.  I requested reconsideration, and now am appealling to OPM.  That is about all you can do.  Have you considered going through the process of reconsideration and then appealling?
     
    Good luck to you.
    GSBS  
    #15 Posted : Saturday, April 07, 2012 6:50:45 AM(UTC)
    GSBS

    Rank: Senior Member

    Groups: Registered
    Joined: 10/9/2011(UTC)
    Posts: 1,678

    Thanks: 1 times
    Was thanked: 2 time(s) in 2 post(s)
    OUtside wrote:

    That is interesting, indeed.

    But I think it gets more interesting, too.

    BC page 132 says the rate for emergency services will be the greatest of the Medicare rate, or 100% of the UCR, or based on compliance with the Affordable Care Act.

    Good for you for recollecting this change from 2 years ago and doing the research pertaining to the grandfather clause. But is the grandfather clause applicable with respect to page 132 of current brochure?

    Yes, although I heard about this Obama legislation from 2010, it only applies to new coverage obtained after the middle of 2010. The UCR is what BCBS bases their charge on. It seems with a non participating provider they use the local Medicare rate if available for the ER Doctor, or it would be paid even lower if no medicare rate is available, as I was so educated by the BCBS rep. Just how low can they go? How disgusting to learn this. Again, I am supposedly responsible to make up the difference. I will  never return to this facility that is rated a 2 out of 4 stars on the FEP site. Lowest rating in the County. Almost a warning to stay away. Plus its dirty.
    penelope1440 wrote:
    I am in a similar argument with BC/BS now over an emergency room visit last year.  I requested reconsideration, and now am appealling to OPM.  That is about all you can do.  Have you considered going through the process of reconsideration and then appealling?
     
    Good luck to you.
    Thank you very much! I guess I brought this up because it happened to me when I lived in a major metro town, and this routinely happens at small town hospitals. Unless your coverage started post 2010, page 132 spells it out, there is no ER reconsideration under the new regulations. Of course the same basic thing applies if we accidentally use a non participating facility or provider for any other service paid at 65%/35% last I looked? The contract is clear, my head wasn't. I was on my way to the Arizona BCBS fully participating Hospital when I saw there were no victims in my local facility. So I popped in there as it is not a good idea to drive when you are injured or sick. In fact my thinking was cloudy for at least two weeks after I hit my head. I had a slight suspicion this billing thing would happen, yet knew Obama had enacted new rules. That it doesn't apply to those who are already insured, and that the special higher rate paid per the rep at Blue Shield is tied to the Medicare Rate for ER care makes me sick. If it was tied to that rate, why do I need to pay another $1000 for non covered charges?  If only there was a perfect plan. As it is BCBS Standard is one of the premium plans offered by OPM. Is there anyone who has a great FEHB plan or could suggest one?  NoSleepy
    GSBS2012-04-07 16:05:56
    Angel1955  
    #16 Posted : Saturday, April 07, 2012 12:06:06 PM(UTC)
    Angel1955

    Rank: Senior Member

    Groups: Registered
    Joined: 11/7/2009(UTC)
    Posts: 448

    I AM STILL DEBATING ABOUT GETTING MEDICARE B - ONLY THING IS THE OPTHAMOLOGIST WHO DID MY CATARACT DOES NOT ACCEPT BC/BS FEDERAL UNLESS PATIENT ALSO HAS MEDICARE B - NOW THAT IS A TWIST - - OR I CAN PAY FOR HIS VISITS, SURGERY ETC. PAY FOR IT MYSELF AND SUBMIT TO BC/BS MYSELF.
    THAT DID NOT WORK AT A DC HOSPITAL A FEW YEARS AGO- I PAID THE HOSPITAL, SUBMITTED BILL TO BC/BS FD AND THEY SAID SORRY = WE ALREADY PAID IT - AND IF I WANTED MY MONEY BACK I WOULD HAVE TO GO AFTER THE HOSPITAL. BC/BS FED REP TOLD ME THAT WHEN THEY GET A BILL IN AND SEE MY AGE THEY SEND IT TO ANOTHER DEPARTMENT - FOR A LONG TIME I THOUGHT IT WAS THE GOVERNMENT PSHING MEDCARE B - NOW I SEE WHO IS PUSHING IT
    Angel1955  
    #17 Posted : Saturday, April 07, 2012 12:09:11 PM(UTC)
    Angel1955

    Rank: Senior Member

    Groups: Registered
    Joined: 11/7/2009(UTC)
    Posts: 448

    SO IS IT SENSELESS TO GET MEDICARE B -OR WISE   I AM OVER 65 -
    OUtside  
    #18 Posted : Sunday, April 08, 2012 12:12:33 PM(UTC)
    OUtside

    Rank: Senior Member

    Groups: Registered
    Joined: 8/19/2008(UTC)
    Posts: 684

    Was thanked: 3 time(s) in 3 post(s)

    GSBS, finding out whether the Affordable Care Act revision you discussed is in effect in fehb shouldn’t be too difficult by making inquiries and posing the question. I don’t know the answer and have not made the inquiries, but I think I would speculate it’s probably in effect in fehb.

    I would speculate this for several reasons, the best one being the BC brochure on page 132 refers to the Act in the emergency services paragraph. Another is the 2011 brochure under ‘how we change’ refers to several provisions of the Act becoming effective January 1, 2011. And the info posted above refers a link which says plans using grandfather status must disclose this in plan materials (I have not scrutinized the BC brochure searching for such disclosure).

    I think if I had this problem I would carefully re-read pertaining brochure sections, particularly page 132 until thoroughly understood, then make inquiries to confirm understanding, including of instances given so far. For example, an earlier post indicates if no Medicare rate available, a lower rate would be used. But page 132, 6th paragraph, says if no Medicare rate is available, 60% of the billed charge is used. Sixty percent of a $1400 billed charge would be $840, $285 higher than a plan allowance of $555.

    But the 7th paragraph does not mention this, instead referring to the highest of the Medicare rate, 100% of the UCR, or the rate of the Affordable Care Act. If the Medicare rate was used, it would be the highest of the 3, it seems to me, although as the Act isn‘t fully up and running yet, perhaps there wasn‘t a useful number from that quarter.

    Last, the Medicare rate as used for retirees age 65+ is really not an issue in this thread but has been raised several times, so I would just like to offer my view that both a retiree with Part B and without Part B would pay the same out of pocket co-pay for care within 72 hours of accidental injury as discussed on page BC brochure page 82, assuming a Medicare rate of $555 and doctor non PPO. I say this because the doctor would be limited to charging 115% of the Medicare rate = $638.25 in both instances. For retiree with Part B, Medicare and BC would cover the $555, requiring the retiree to pay the additional 15%, or $83.25.

    For retiree without Part B, according to BC brochure page 82, there would be no deductible and retiree would pay the difference between the plan allowance (same as Medicare rate) and the doctor’s bill (limited to 115% of the Medicare rate), which comes to the same number for out of pocket, $83.25.

    OUtside  
    #19 Posted : Sunday, April 08, 2012 12:23:51 PM(UTC)
    OUtside

    Rank: Senior Member

    Groups: Registered
    Joined: 8/19/2008(UTC)
    Posts: 684

    Was thanked: 3 time(s) in 3 post(s)

    In the example just quoted where doctor giving care for accidental injury is not PPO, doctor must also not accept Medicare assignment. If doctor accepted Medicare assignment (though not PPO), out of pocket costs in both cases would be zero for retirees under BC Standard.

    GSBS  
    #20 Posted : Sunday, April 08, 2012 1:08:55 PM(UTC)
    GSBS

    Rank: Senior Member

    Groups: Registered
    Joined: 10/9/2011(UTC)
    Posts: 1,678

    Thanks: 1 times
    Was thanked: 2 time(s) in 2 post(s)
    Wow you are incredible! My head still hurts from the smash alone, but it seems from what I read about Gradfathered plans I stand no chance as this new provision is somewhat clear & only for new coverage commencing after 3/2010. My FEHB coverage has been active since 1998. Nothing positive in this page at all? 
     I even learned this ER visit was billed with the same code as my previous inpatient illness stay in 2010. Why is this charge more and the reimbursement less just because I hit my head?  I'd much rather pay that $83.25 instead of the billed balance of $900.  Thank you again for your examples and advice. It seems like you absolutely understood this problem! If you find a good answer or even yet a better health plan please PM me! I'm still paying off the last ER visit @$10 a month, no interest. That they wouldn't take the $750 BCBS check as payment in full is beyond me?. Wanted me to send in the check and then we maybe could talk about it. 
    GSBS2012-04-08 22:25:54
    Rss Feed  Atom Feed
    Users browsing this topic
    Guest
    2 Pages12>
    Forum Jump  
    You cannot post new topics in this forum.
    You cannot reply to topics in this forum.
    You cannot delete your posts in this forum.
    You cannot edit your posts in this forum.
    You cannot create polls in this forum.
    You cannot vote in polls in this forum.


    This page was generated in 0.824 seconds.