The parents of my childhood best friend are on their local Blue Cross/Blue Shield (BCBS). They’ve almost always been on BCBS. And that is how they see their insurance. BCBS gets a premium and they get to go today to wherever they could go in the past because that was what BCBS covered. They got hit with an out of network bill for a podiatry visit as they went to a podiatrist that they have seen for years.
The problem is that they just retired. Mr. H hit 65 in May, and Mrs. H turned 65 in June. They had switched their coverage from a BCBS large group employer sponsored plan with a gigantic network to a BCBS Medicare Advantage plan with a large but not gigantic network. One of the fall-out providers was their podiatrist.
They did not know that their networks changed when they changed product lines. They talked with the billing manager at the podiatrist and they’ll get it sorted out but they were surprised that there was no single BCBS network.
They had been in BCBS since their late 20s. Since then they had large group BCBS, they had small group BCBS, they had BCBS CHIP, their grandson (who is quite adorable as he discovers his toes) was born on BCBS Medicaid, their older grandson is on BCBS CHIP, their son and his wife are on BCBS Exchange. One of their parents was on BCBS Dual Eligible Medicare/Medicaid Special Needs Plan (SNP). They thought it was all basically the same with different ID cards and different marketing material. They were extremely sticky to the local BCBS.
From a business point of view the stickiness was a significant objective of BCBS to offer a full suite of products for all lines of business. The data geeks at BCBS have thirty five years worth of claims data, thirty five years of phone call data, thirty five years of prescription data, thirty five years of text data. The data geeks are fairly confident that if Mr. or Mrs. H. go in for cost-efficient preventative care, the insurance company is likely to see profitability gains through claims avoided six months, twelve months and thirty six months down the road.
That is the upside of being a comprehensive carrier participating in all lines of business with a diverse array of products. People may bounce around within the company, but their data stays within the boundaries of the firm. And from there, the challenge is managing the data to maximize health while minimizing claims expense.
The downside of course to running a diverse set of businesses is that each segment has its own quirks and developing the expertise to be a great Medicaid plan will often conflict with the the imperatives of being an extremely attractive large group employer sponsored carrier. The work around is kludges such as seventeen distinct networks with marketing derived identification that really does not say much about who is in and who is out.
I’m in the same situation, BCBS now but a “subsidy” from my employer when I retire. I have to figure out what to do but I have at least a year.
Oh, God, when we wil just have single-payer health care?
I have discovered that you can talk to your out of network provider about being in the network. If they are unhappy about the compensation, you can throw in some more money, and it’s still cheaper than paying out of pocket.
That’s all that is required: a willingness to do the paperwork and finance negotiations.
Or how it changes from year to year
@Betsy: When a state finally manages to institute one. It’s gonna be one state at a time at first. And something tells me it will be out west.
Richard: any thoughts on the Hawai’i 1332 waiver? I tried to get info on it yesterday but the CMS website is DUMB on mobile.
I am retired now but when I was in healthcare, taking money from a patient to make up for the lower rate of compensation was a no-no and subject to sanctions. IIRC, it is also a listed as fraud under Medicare . . . so I wouldn’t recommend it for Medicare patients.
Mmm…my experience with BCBS 25 years ago was so bad, I went without insurance for a few years and have never picked them since. Basically they were not cheap when I was poor then I switched bank accounts and authorized the new account to pay and closed the old account. They took the money from the new account AND tried to take it from the old account and then said I hadn’t paid. 2 months in a row. I had to call long distance, be on hold for 40 minutes to and hour and get told their computers were down so they couldn’t see anything AND COULD I CALL THEM BACK tomorrow. No they couldn’t write down the problem and check when the computers were up and call me or give me a faster direct line………Repeat over several weeks. I was working long odd hours and it was not easy for me to find time in business hours to sit around on hold that long for nothing and pay for it too. Long distance phone bills used to be significant, remember? I could not fix their error so I had to end the insurance which I had really wanted. I had no other options then. It also left me discouraged.
I know I am relatively lucky. I went back to school and ended up working for the state with good insurance. 20+ years later and I get cancer and had NO problems with my insurance. Low out of pocket costs too. I thought of other peoples situation all the while I was sick. I still have resentments about that company though and couldn’t leave this thread alone.
@Yutsano: I’m still reading the 1332 from Hawaii — from my initial read, it seems to be a good idea to restore the pre-PPACA status quo as the Hawaii employer mandate is WAY WAY WAY stronger than the PPACA employer mandate and a much higher level of actuarial value coverage is provided for people.
@Scout211: thinking about it, taking $ directly, and off the books, sounds like both a shakedown and tax fraud.
On the other hand, all those letters coming in with demands for extra payments for what the insurance didn’t cover? Good ole American ingunity.
When employed our Bl-X offerings bounced from BCBS in whatever state we resided, to BCBS Choice and Chip Mass (really liked) to BCBS Empire (NY)- ptooi, currently Anthem BC (Indiana I believe) which I have not had an issue with. I’ve never had an issue with network, as I haven’t been seriously ill or had chronic or rare med problems. Most issues were slow BC payments or them claiming lack of referral, which was always wrong. Weirdly, our Anthem plan does not require referrals. As long as I check that the doc accepts my member number, anything goes. That is nice.
@Scout211: Figures. Thanks for letting me know!
Crap, that reminds me, I need to see if I can get an appointment with a new ADHD psychiatrist. My previous one dropped Cigna because they decided that she was spending too much time with patients. Her primary practice is pediatric psychiatry so, yeah, she was kinda pissed.
@Betsy: How long, oh Lord, how long?
Every time my dr or ins co has to argue with the ins co I wonder why We The People continue to put up with this.
Last week was a classic example of the “violence inherent in the system.”
All week I was making phone calls; to the doctor’s office to get the right codes, to the insurance company to find out the next hoop to jump through, back to the doctor to get the next puzzle piece lined up. And they would call from some weird number than changes all the time, so I don’t always answer my phone, thinking it’s a spam call. Then I get a voice mail, directing me to still another number, and a 16 digit “case code.” Only I call the new number, and they tell me it’s the wrong number to call and they don’t know anything about the case code.
Finally get approval and told I can obtain the prescription from my doctor. I do so. Then I get another call saying they will be sending me a list of approved places to order it from.
First I’ve heard.
@WereBear: And, of course, I had already ordered it. Was it from a place on the approved list? I don’t know, because they have yet to send the list to me.
It seems to me that this is yet another advantage of integrated payer/provider networks. Yes, they tend to be narrow, but there’s never any confusion about who is covered and who isn’t, or changes in who is covered depending on which plan you have.
Yeah, I’m coming up on Medicare in January, and I have a strong bias toward staying with Kaiser for just this reason. I need to sit down with all the material I’ve been sent from various sources and figure out the details, though.
My husband and I are at his brother’s, attending to his brother’s last days thanks to cancer. He’s lucky that he has a state ins. plan so all us covered, but I do want to strangle the oncologist’s office for gross callousness. His employer and hospice both said yes, he should be on long term due ability, he paid for ins and he’s entitled but did office is slow walking and refusing to fill out one line the way the ins office said to. My BIL shouldn’t have to deal with crap like his in his last few weeks of life, it is simply banal paper shuffling evil.
@StringOnAStick: My condolences on this sad time.
Yes, they do all this to people who are sick. Which is another level of terrible.
@WereBear: Thanks, I appreciate that. His anger over it is turning him into a tyrant towards his wife and it sucks to see that. I hope they get it resolved today sdo he can stop acting crazy over it.
@Richard Mayhew: I didn’t think PPACA overturned the Hawai’i employer mandate. I could be wrong there, but yes it was pretty much if you worked your employer insured you period. It’s why my birth islands probably could go to single payer if they chose because they were almost there in re: full coverage of everyone.
You may have heard that bcbst dropped out of the marketplace in the metropolitan areas here in Tennessee. They said they were losing money.
I thought they could raise rates to cover actual costs when they shows has the facts and there was a risk corridor to make up for insurance company loses.
What do you think the real reason they are leaving.
I’m so discouraged at how difficult everything has been here in this non-expansion state.
Sorry for typos . Unable to edit my comment
@Laurie: I am not in Tennessee, I have never deeply analyzed the Tennessee market. So my knowledge is limited.
First there is no 2017 risk corridor. The risk corridor was only ever supposed to be in place through 12/31/2016.
Secondly, I am guessing that BCBS/TN is looking at their competitors in the counties that they dropped and analyzed the situation of pricing and networks. From that analysis, I SPECULATE WILDLY OUT OF MY ASS that they figured that they would get a lot of bad risk without sufficient risk adjustment payments to transform bad risk into neutral or profitable risk. And the only way to avoid very bad risk is to pull out. Again, that is pure speculation on my part.
Yes. Thanks for your insight on what might be behind this. We did have a co-op that started year two and got a lot of enrollees but did not survive. BCBS TN created a new narrow network and they had the lowest price silver plan for every other year.
Just wonder what makes this state different enough for marketplace not to work for the insurer. Does it just boil down to the unhealthy population?
@Yutsano: Nope, we still have the employer 20-hour per week must supply healthcare coverage law out here. I know because my wife’s sleazy boss needed them to work more than 20 hours for a few weeks and wanted them to sign their rights away. I know the ACA has been a disaster for Hawaii, almost no one enrolled because we already had such strong employer healthcare requirements. A ton of money ended up being wasted.
You call it SNP? At HMSA we call it DSNP or “D-snip.” Currently putting the final touches on our MAPD software (which has a DSNP option) since OE 2017 is coming up!