Blue Cross/Blue Shield Plan Changes Beginning to Impact Patients, Providers

As BCBS plans roll out their strategies to eliminate the BlueCard plan, more and more diagnostic laboratories are finding themselves holding the bag after having provided medically necessary testing in good faith and accepting assignment from patients to file insurance claims on their behalf, only to find that the plans are paying the beneficiaries instead of the labs. As labs are well aware, obtaining payment from a patient is costly and often ineffective, with collection success rates being as low as 50%. Moreover, classifying providers as out of network that were previously being paid as in network under the BlueCard plan is now resulting in plan members being saddled with greater cost-sharing for lab services, through no fault of their own.

Plans that are not honoring the patient’s documented assignment of benefits to non-contracted lab providers, and that are paying the enrollee instead of the provider, are also at odds with legal precedent. The refusal to honor assignment of benefits is, in fact, illegal in an increasing number of states, with at least twelve states currently having laws in place requiring plans to honor assignment of benefits.

By ignoring the assignment of benefits as identified on a claim and not providing an explanation of benefits to the provider submitting the claim, BCBS procedures force the provider to pursue a costly manual process of repeatedly having to perform on line follow up to determine the status of the claim, followed by an effort to pursue the patient for collections. The harm to enrollees caused by this protocol is also of serious concern since they are put in a position of committing insurance fraud when they unwittingly use the funds for other expenses and cannot pay the lab. Blue plans that knowingly and intentionally disregard an assignment agreement between a beneficiary and a provider are demonstrating disregard for both the lab providing services in good faith and the patients who are now put in the position of coming out of pocket for necessary services and having to file their own claims manually. This process is not only burdensome for patients, but also flies in the face of federal efforts to streamline the administrative burden of filing claims by creating standard electronic claims processing protocols.

Providers have been absorbing the cost to date, but as volumes of unpaid claims increase, the burden will be shifted to patients, who will be facing higher and higher costs for their healthcare. Employer Groups will see more complaints from employees under a Blue Plan, while patient advocacy groups and state insurance commissioners will be compelled to intervene on behalf of patients.