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Thread: Please Help

  1. #1

    Lightbulb Please Help

    AAPC: Back to School
    Does anyone know where I can find or have the fee schedule Horizon Blue Cross Blue Shield uses for out-of-network providers? They told me they use 2007 ingenix RBRVS fee schedule but I cannot find it. Im very confused and would really appreciate any advice. Thank you for your time in advance.

    Stella, CPC

  2. #2
    Join Date
    Apr 2007
    Lubbock, TX


    The answer to your question will depend on the plan - if the plan is one that participates in Blue Card, then you should receive your regular BCBS contracted rate. The non-blue card plans get tricky...

    Officially, they say that they pay 80% of R&C:
    What are the out-of-network benefits?
    NJ DIRECT10 provides reimbursement for out-of-network coverage at 80 percent of the reasonable and customary fee schedule after deductible, for most services, while NJ DIRECT15 provides reimbursement for out-of-network coverage at 70 percent of the reasonable and customary fee schedule after deductible for most services.

    Here's one explanation of OON benefits:

    So the question is, where are they getting their R&C rates? Call customer service and advise them that you need full disclosure of the payment policy applicable to your claim, including the methodology used to determine R&C rate, IN WRITING. You're entitled to it by law, so don't take 'no' or 'that's not possible' as answer. Go up the food chain if necessary. Good luck! Meanwhile, here's an article that could be relevant to your issue; just something to keep in mind.

    Latest Practice by Insurers Targeting OON Benfefits

    Certain payors (e.g., Oxford and Aetna) have introduced a new out-of-network policy that reimburses services received from out-of-network provides based on a percentage of the Medicare rate for the service, rather than the "reasonable" or "prevailing" charges. The practice is designed to deprive New Jersey out-of- network surgical centers and other out-of-network providers of the benefit of the commercial arbitration process mandated by the New Jersey Department of Banking

    and Insurance ("DOBI"), known as MAXIMUS, which arbitrates according to policy payment guidelines set forth in the applicable patient's insurance policy). Currently, under an insurance policy that prescribes a "reasonable" or "prevailing" charges benchmark, out-of-network surgery centers typically argue to the MAXIMUS arbitrator that a certain insurer that underpays a claim is breaching its obligation (under the insured's policy) to pay the "reasonable" or "prevailing" charges incurred by the insured (i.e., the underpayment is below the "reasonable" or "prevailing" charge). However, under the new policy language, no such argument will be available because such policy would prescribe a definitive payment benchmark (a percentage of Medicare) according to which the insurer must compensate out-of-network surgical centers. Thus, as long as an insurer pays out-of-network surgical centers in accordance with the aforementioned definitive payment benchmark, an out-of- network surgery center would not be able to argue to the MAXIMUS arbitrator that it was underpaid by such insurer.

    The impact of the foregoing practice on the profitability of surgical centers depends on whether policies prescribing the aforementioned payment benchmark will gain popularity in New Jersey's insurance market, and whether such practice is effectively challenged on legal grounds.

    Currently, there is nothing in the DOBI regulations that explicitly prevents payors from engaging in the aforementioned practice, or placing restrictive caps on plans. However, Assembly Bill A2882 (Conaway) would instruct DOBI to prohibit plans that have caps, restrictions, or anything else for out-of-network providers. There has been no reported action with respect to this legislation since the date of its introduction, June 14, 2010.


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