Outcome of 1st Appeal - Fed BCBS for VSG

My letter arrived yesterday from Federal BCBS. They said I was going to get reimbursed for my surgery. However it was a fraction of what I paid. According to the 2009 Service Benefit reimbursement is made at 70% of the Plan Allowance for going with a non participating provider.    The following is what was in the letter. To me it's complicated.   For physicians and other covered health care professionals that do not contract with the local blue cross and blue shield plan, our allowance is equal to the greater of 1) the Medicare participating fee schedule (MFS) amount for the service or supply in the geographic area in which it was performed or obtained (or 60% of the billed charge if there is no equivalent Medicare fee scheduled amount ) or 2) 100% of the 2009 Usual, Customary, and Reasonable (UCR) amount for the service or supply in the geographic area in which it was performed or obtained. We may refer to our allowance for Non-participating providers as the "NPA" ( for "Non- participating Provider Allowance"). This information is found on page 123 of the 2009 Service Benefit Plan brochure.   

The self-pay amount paid to the doc was $12,500.00. I received from Federal BCBS reimbursement:   Removal of the Lap Band - $2,221.00 VSG Surgery - $2,270.00.  If I was entitled the 70% I would have received around $8,750.00.    I'm going to call the Reconsideration Specialist that signed my letter and ask her some questions about the geographic area and the 70% reimbursement.   If anyone has any comments or thoughts please feel free to say so.      Please don't get me wrong. I'm grateful for getting some of the money reimbursed. However, if I can get the full 70% I would like to. Know what I mean?    Thanks. babygirlinokc   

Good luck BabygirlinOKC!  You are treading on ground I have no understanding of - how they calculate fees and charges, doesn't make sense.  Did the amount you paid your surgeon also cover your hospital expenses?  Will BCBS be reimbursing the hospital separately?  Is what they paid for the surgeon's fee only?  For the three surgeries I have had (two carpal tunnel release and one hysterectomy), I was billed separately by the hospital, the surgeon and the anesthesiologist. 

Let us know what you find out so we can all learn about this process.

Luanne

It's very complicated for me too.  I just hope that OPM will grant me what I'm entitled to. 

BCBS paid me already for the hospital on a different claim.  The surgeon and assistant surgeon claim is a separate claim that includes the removal of the band and the vsg.

Thanks for responding Luanne. 

I think the 70% is of the 'Allowed Amount' referenced in 1 or 2.  The EOB you received should mention what the dollar amount of your coinsurance is (the 30%) so you should be able to back into what their allowed amount is.

It sounds like the best case scenario would be 70% of 60% of the billed charge.
If there is no Medicare Fee schedule, then the allowed would be 60% of the charges.  So the Allowed amount would be $7500.00    70% of this amount would be $5250.00.  I think you received $4921.00 (assuming the VSG is $2700 - not sure what $2,2700 is).

Assuming you did receive $4921.00, then the allowed amount would have been $7030.00 which leads me to believe that Medicare had a fee schedule, and FEP used it.

If you have the exact codes the provider billed, you can look up the CMS fee schedules at this link:

http://www.cms.hhs.gov/pfslookup/02_PFSsearch.asp?agree=yes& next=Accept

Hi GigiNorth, Thanks for replying.  I checked a website for the Medicare Fee Schedule, I believe that's what the figure was, when I put in the cpt codes.  It still did not make any sense to me.  Anyway,  he is the actual amounts on my letter they sent me:  Please let me know what you think.  Dr. Broussard's Claim
Date of Service	Procedure Code	Amount Billed	Plan Allowance	MFS or 60% of Billed	Ded	Plan Paid	30% Co- Insurance	Amount Over Allowed	Patient Liability
5/20/2009	43774	$5,000.00	$1,128.40	$804.07	$0.00	$789.88	$338.52	$3,871.60	$5,000.00
5/20/2009	43843	$7,500.00	$1.481.20	$1,061.17	$0.00	$1,036.84	$444.36	$6,438.83	$7,500.00
	TOTAL	$12,500.00	$2,609.60	$1,865.24	$0.00	$1,826.72	$782.88	$10,310.43	$12,500.00
Dr. Walton's Claim (Assistant Surgeon)
Date of Service	Procedure Code	Amount Billed	Plan Allowance	MFS or 60% of Billed	Ded	Plan Paid	15% Co- Insurance	Amount Over Allowed	Patient Liability
5/20/2009	43774	$2,500.00	$225.68	$128.65	$0.00	$191.83	$33.85	$2,274.32	$2,308.17
5/20/2009	43843	$3,750.00	$296.24	$169.79	$0.00	$251.81	$44.43	$3,453.76	$3,498.19
	TOTAL	$6,250.00	$521.92	$298.44	$0.00	$443.64	$78.28	$5,728.08	$5,806.36
This claim shows the coinsurance to be 15% instead of 30%. This claim originally applied preferred benefits in error
resulting in an overpayment. However, the Plan will not be pursuing reimbursement of the initial overpayment and the
coinsurance will remain as 15% of the Plan allowance on the adjustment.

I would ask them what the rate for : 2) 100% of the 2009 Usual, Customary, and Reasonable (UCR) amount for the service or supply in the geographic area in which it was performed or obtained.

They used the MFS as the Non Par Allowance (NPA) - but based on what you quoted in your first message, they should use the greater of  MFS or the UCR - I would be surprised if MFS is the higher since Medicare is notorious low in their reimbursement levels (which is why most surgeons will not accept Medicare even though there are minimal hoops to jump through).  Ask them how they calculate the UCR fee schedule - if they use a third party vendor to calculate that rate, what is the vendor.  There have been several lawsuits involving non par allowances etc -

I called them and they said they do not have UCR for this geographic area.  They went with the MFS. 

Another thing came up yesterday.  I called my doctor's financial office, Tanesha, I asked her if she had received a check for me on the readjustment claim of $12, 500.00 in the amount of $251. 81?  She checked and it had not arrived yet.  BCBS should have sent it to me, but somehow it was going to be sent to the doctor.  Tanesha said when she receives it she will reimburse me.  Tanesha also mentioned if I had received a check in the amount of 2045.40, for the claim of $12,500.00?  It was an EOB, dated 10-19-09 that BCBS sent to her saying that I was going to receive a check in that amount.  She also received another EOB dated 10-21-09 BCBS was going to send me a check in the amount of $1826.72 for the claim of $12,500.00.   I had received that check on Saturday, $1826.72. 

I called BCBS, Tammy T. and asked them what about the $2045.40 check.  They said they had no record about that amount of reimbursement check in their system.  Tammy was going to call my doctor's office and talk to Tanesha about that EOB.  Tanesha told me that Tammy T. asked her,  why did you tell Virginia about the $2045.40 reimbursement check?  Tanesha said,  that was something they are supposed to do.   I as a patient I have the right to know what they have receive in reference to my account, EOBs.  Tanesha faxed her a copy of the EOB that she received from them, that they supposedly do not have record of.  Tammy said she would call me back when she finds out about the $2045.40 check.  Still waiting for her to call, better not hold my breathe.....LOL.

I wonder if it was not a change because of a miscalculation and they sent the check for $1826.72 instead of $2045.40.  What is your opinion?


Thanks
babygirlinokc

Sounds like they caught their error prior to the check being cut (but not prior to the provider remit going out).  Sometimes I think if the providers are non par it may be better to say I'm a self pay and then ask for reimbursement later :)

Usually when they pay the member, they do not even tell the provider what they are going to do.

That's true.  I have learned my lesson and I'm not going with an out of network doc anymore.   

Thanks.