BlueCross BlueShield of TN is not the bad guy
I watched a news story on Channel 5 last night and needless to say was more than a little disappointed in how unfair the story was. It seems they wanted to tell one side only making the big bad insurance company the bad guy again. As a group insurance broker we work with employers and employees trying to manage benefits and costs. One the biggest challenges today is the high cost of prescriptions and all the new specialty prescriptions being prescribed. That is exactly what is happening in this story and Channel 5 makes it sound like the patient is going to go blind because of this new "policy change".
What BlueCross BlueShield of TN is not saying they are not going to cover this medication nor are they going to limit it. All they are doing is requiring members to purchase it through a Specialty Pharmacy where they have some control over the cost of the medication. This story is about Lucentis a shot that treats macular degeration. What they failed to mention is that the medication costs $2,000 per shot.
How much Dr. Awh charges BlueCross of TN for this medication I do not know. Nor, do I know how much the specialty pharmacy charges. I do suspect there is a pretty big difference in cost between the two and while patients and doctors may need to order the prescription the day before the office appointment the goal of BlueCross BlueShield of TN is help control costs and medical spending for all of their members.
I am writing this because we get a lot of calls from frustrated members because the expect their expensive treatments and prescriptions to be immediately covered with no questions asked. For the most part, everyone gets the treatment or prescription the doctor is ordering but I think it's important that the insurance companies do everything they can to make sure that treatment or Rx is necessary since it is saving me and our clients money.
Here are the resources I am using in this post.
Cost of Lucentis
News Channel 5 story
Posted on 02/28/2020 10:31 AM by David Moore
Surprise Medical Bills - Buyer beware
One of the biggest claim issues we are now dealing with is our clients getting bills from out of network providers and labs even though they used an in network facility. In the past this rarely happened but it seems some doctors have found out they can make more money by not contracting with an insurance companies PPO network. Even more worrysome is hospitals and out patient surgery centers knowingly allow these providers to work on their patients even though they know the problems it will create.
In the past insurance companies were more tolerant of this abuse and providers thought they had found a loophole to higher reimbursements. Because it became so common, the group insurance companies began following the legal contracts they have in place which allows them to not pay for these procedures as in network benefits. Most policies have a separate deductible for out of network claims which is where these claims get filed. That creates a separate bill for the insured and unfortunately there are no in-network discounts so the provider can bill whatever they want for their services.
Congress and President Trump have promised to create legislation to stop this abusive practice. Of course, they have also promised price transparency and lower prescription costs. We have yet to see those changes and in an election year they need all the Super Pac money they can get.
It is estimated that 20% of all surgeries and hospital stays now have out of network charges with an average cost of $2,011. The scary thing is we are seeing it regardless of which insurance carrier they have and it seems most hospitals are allowing it to happen as well. Even worse, there is very little you can do as a patient on the front end to avoid this from happening.
It is very important for you to understand, this is not the insurance companies fault. This is the hospitals fault loud and clear. They are allowing non contracted doctors to knowingly work on their patients and bill their patients huge amounts they should not owe.
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Posted on 02/12/2020 11:24 AM by David Moore