Monday, November 9, 2009

Fussing With Blue Cross Blue Shield

I am having problems with getting adequate reimbursement from Independence Blue Cross Blue Shield and sent the following appeal:
"I would like a professional (non-machine) review of the reimbursements made to out-of-network providers listed above as  the allowed charge is far below the usual and customary rate.  These providers rates are within market norms for their level of expertise and specialty. 
I have been in Blue Cross Blue Shield of Massachusetts plan and have submitted claims for Dr. XX  and Dr. YY in a previous Independence Blue Cross plan  as an out-of network provider and both the allowed rate and  my reimbursement have been much higher. 
The allowed rate must reflect surveys based on the geographic area and as such the rate Independence Blue Cross Blue Shield is far too low.  I believe that the  software, Ingenix is being used to calculate allowed rates and reimbursement rates and is likely the cause of the lower reimbursement.  Ingenix has been the target of a class action suit in New York state for “price fixing” due to its artificially low reimbursement.
Please provide me a copy of the formulas used to calculate my reimbursement.  I would like an increased reimbursement from the provider claims that I have already submitted and I would like to ensure that future claims from out-of-network providers are reimbursed properly"

The problem is that the reimbursements we are getting back from the insurance company are way too low.  I mean $40 on a specialist visit and $20 for a nutritionist.  This is not on a crap policy.  We are paying $1700/month for husband and wife.
What has happened is that Ingenix deliberately is setting the rates too low.  There is no way that in my neck of the woods that any medical specialist bills at these rates.  They are about 1/2 that of a general practioner in-network.

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