John Strein

Review of Blue Care Network

We have had BC/BS PPO for several years and was ve...

We have had BC/BS PPO for several years and was very satisfied. Recently we were switched to BCN HMO. My first experience with this "coverage" has been a nightmare.

A simple preventative procedure that I have had done previously because I am high risk for cancer in this particular area will not be covered. The out of pocket cost $5000+. I have "insurance" put it is essentially useless, AND, I am paying thru payroll deductions for this "coverage."

Today I have talked with the doctor's office 3 times, their billing expert twice and a representative from BCN including a supervisor. That person said it could be covered if the billing department coded it differently. The billing department says they can only bill it one way which is the code that BCN will not cover or it is billing fraud.

The BCN supervisor went so far as to say that it would behoove me to get familiar with ICDM codes!! So, evidently patients now should be familiar with medical billing codes to have a chance of certain procedures to get covered. Seriously? It is up to us, the subscribers, to educate ourselves in a very complex area of our health care system. That is not realistic.

So the two sides, the doctor's billing agent and BCN, will not budge. The billing agent says this is the code, the only code they will use for this procedure and BCN says that code is not covered but there could be other codes they could use where it might be.

This is life with an HMO. I was with Health Plus several years ago for just two years and my experience there was about the same--------they will deny most procedures but if one is persistent and has the time to appeal once, twice etc., most of the time one will get the coverage. Time will tell whether this eventually gets covered. I will make the time to appeal and make phone calls.

Meanwhile Medicaid patients who pay nothing for their coverage receive benefits, most of the time for nothing out of pocket. Isn't the American health care system great.

And folks, I am not talking about a heart transplant here. I am talking about a diagnostic colonoscopy. Not covered according to the BCN because of the code the billing agent would use and the billing agent says that IS the code and that's it. Sorry for you BCN subscriber.

Here is the kicker; if the polyps develop into cancer the surgery and followup radiation would be covered according to BCN. As long as they are coded correctly, of course! Sounds a bit absurd but this is the reality I am faced with today.

Stay away from any HMO if you can. And, if you can qualify for Medicaid, do so. What used to be a "bare bones" government health insurance for the very poor has developed into today's "Cadillac" plan. Seems backwards to me. Those that pay (a lot) for health insurance can't even get the services these individuals receive.