What Blue Cross Blue Sheild won't pay...

freeio

I had the fun experience of personally visiting the Hoover, Alabama headquarters of Blue Cross Blue Shield of Alabama. The primary issue was what "usual, reasoanble, and customary" means, since I had found that not one of their preferred providers I used for surgery, oncology, and such charged or accepted the small amount that BCBS was offering. I suppose I am a bit of a skeptic, but I got the distinct feeling that there is a distinct "Catch 22" scenario here, where they are the big guys, and they can make exactly whatever rules they see fit.

The net result was that the fine surgeon (part of BCBS PMD and PPO network) charged more than twice what BCBS was willing to pay, and I really am stuck for the difference. This kind of difference is true of every specialist used, without exception. The net result is that although I am nominally insured, the roughly $100,000 that this one cancer episode costs wil leave me with about $25,000 of bills left over. Ouch.

So, exactly what does "usual, reasonable, and customary" mean with respect to BCBS? The answer is ABSOLUTELY NOTHING. It is whatever they declare it to be, and no more.

They say that emotional state affects one's recovery, and right now I am not a happy camper. Yeah, I know: Deal with it. Oh well...
_________________
-------------------------------------------------
whipple procedure, Oct. 21, 2004
28 days of radiation
56 days of Chemo using Xeloda
diagnosed as progressive recurrent pancreatic adenocarcinoma (Stage IV) Jun. 20, 2006
was treated with gemcitabine, oxaliplatin, and tarceva, which all failed.
Cancer blog: http://diehlmartin.com/cancer.html

mkelly

Usually doctors that work specifically with plans such as BC/BS have contracted ratese and even though they bill considerably higher (I suspect as a way to get insurance companies to pay more), they cannot bill the patient for the difference.

Perhaps this varies by plan, but you might want to check that out.
_________________
39; (7/03) 2.5 cm lump in rt brst; (7/05) widespread in rt brst with 3.5cm largest
Currently in chemopause
Invasive Ductal Carcinoma; ER/PR+, her2-; Stage 2 both times
(7/03) Lump, Sentinal Node Biopsy; (10/05) MRM, lyph section (2 of ~13 + lymph nodes)
(2006) A/C 4 rounds / weekly Taxol 10 of 12 rounds; Radiation & Tamoxifen

3pturk

freeio,
I have to agree with mkelly. I have BCBS of Michigan and the drs. do agree to certain rates in order to be a part of the program. You should not be held accountable for the difference, the drs. should accept the lower, agreed upon amount. All of my drs. billed agreat deal more than they actually received. Look into this further before you pay those bills.
Wishing you luck.
Jill
_________________
Dx 3-17-05,breast cancer
40 yrs young, Invasive Ductal Carcinoma, 2.5cm
ER+/PR+, Her-2/neu Negative, Grade and Stage 2
1 Sentinel node pos. 17 neg., chemo AC/Taxol ,
rad.tx

3pturk

I wanted to add that you probably have a deductible that needs to be met before the full coverage kicks in.
God Bless and be well.....
_________________
Dx 3-17-05,breast cancer
40 yrs young, Invasive Ductal Carcinoma, 2.5cm
ER+/PR+, Her-2/neu Negative, Grade and Stage 2
1 Sentinel node pos. 17 neg., chemo AC/Taxol ,
rad.tx

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