Re: Out of state insurance plans

[Guest guest]

Hi Diane,

We are also having a problem with out of state BCBS. I am in NYC. The

reimbursment for a person who receives treatment here but has a home plan out of

state-particularly Illinois is REALLY low. There is no consistency at all. I

treat 2 people , both BCBS, both claims get sent to the SAME place. One has a

plan from Illinois and one from NJ and the reimbursement is vastly different.

And it is unacceptable in my mind. The people at BCBS frankly can't even

explain it to us!

a Meloe

>

> I operate a peds clinic in Massachusetts that provides OT,PT, and ST. We are

in-network providers for BCBSMA and are having consistent difficulty verifying

benefits for patients with BCBS plans from other states. Does anyone know if

there is a specific rule which determines which state's coverage policies apply?

Is it the state that the policy was written in or the state in which the

services are delivered? What about in circumstances where coverage is mandated

by state law, as with Autism services. Would love to hear other's experiences,

it is getting very difficult to explain to parents.

>

> Diane L. Maxson, MS, OTR?L

> Therapeutic Learning Center

> Canton, MA

>

[Guest guest]

Here is an example of how the BCBS Home/Host arrangement works. Let's say a

member of the Illinois BCBS plan goes to a provider in MA. The Illinois plan is

considered the 'Home' plan, and the MA plan is considered the 'Host' plan.

The Host plan (MA) applies provider contracting policies. The Home plan (IL)

verifies eligibility, applies medical policy, and applies benefits. So, the

state-mandated benefits for IL would apply. Hope that helps. Beth Rohrer, PT,

DPT, OCSOutpatient PT, Centreville, VA

----- Re: Out of state insurance plans

Date: Fri, 24 Jun 2011 13:11:50 -0000

Hi Diane,

We are also having a problem with out of state BCBS. I am in NYC. The

reimbursment for a person who receives treatment here but has a home plan out of

state-particularly Illinois is REALLY low. There is no consistency at all. I

treat 2 people , both BCBS, both claims get sent to the SAME place. One has a

plan from Illinois and one from NJ and the reimbursement is vastly different.

And it is unacceptable in my mind. The people at BCBS frankly can't even

explain it to us!

a Meloe

>

> I operate a peds clinic in Massachusetts that provides OT,PT, and ST. We are

in-network providers for BCBSMA and are having consistent difficulty verifying

benefits for patients with BCBS plans from other states. Does anyone know if

there is a specific rule which determines which state's coverage policies apply?

Is it the state that the policy was written in or the state in which the

services are delivered? What about in circumstances where coverage is mandated

by state law, as with Autism services. Would love to hear other's experiences,

it is getting very difficult to explain to parents.

>

> Diane L. Maxson, MS, OTR?L

> Therapeutic Learning Center

> Canton, MA

>

------------------------------------

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[Guest guest]

a

Let me attempt to assist your understanding. The majority of the BCBS plans

around the nation handle their claims this way. A provider lives in a

particular state-in your case NY. They treat patients in their clinic. 99% of

the time, BCBS mandates that you submit a claim to the Provider's home plan. In

most states there is only one place to file a claim and that is to BCBS of that

state. In your case it is a bit more confusing, since there are 5 state of NY

plans. One for Western NY, one for Upstate NY, Empire (NYC) and two others.

You file your claims to the plan that controls the geographic region you are in.

If you are treating a patient with a BCBS out of state plan, then your claim

goes to your " home plan " and they pass it along to the patient's BCBS insurance

company. This is where the challenge starts. BCBS has Physical Medicine

guidelines that deviate from state to state. Some allow so many visits a year

(i.e., MI may allow 50, Iowa 20, some other state 150, etc). Other states will

allow certain CPT codes but deny others. For example, a state might deny manual

therapy because the CPT description indicates massage is a part of Manual

Therapy). Even other states might cap the total amount of reimbursement-like

Medicare does. Others limit the amount of time a patient can be treated (i.e.,

IA BCBS only allows 30 minutes of treatment/45 if you use certain coding

combinations). The reimbursement game is an absolute mess. And it will get

worse due to the fact that companies are consolidating operations, shopping

around for cheaper rates and trying to reduce their cost of insurance-by

increasing deductibles, coinsurances and copays. As companies consolidate their

benefits (auto companies for example), they purchase insurance coverage for all

of their employees nationwide under one BCBS state plan. So Ford Motor might

employ people in NY, but their coverage would be under a BCBS of MI plan (this

is a hypothetical example-but many companies are doing this). So your NY BCBS

plan might reimburse you at your participating provider rates, but you might get

shorted due to the BCBS of MI Physical Medicine Policy.

I am going to sound like a broken record here and many will step up and shoot me

down. I believe the time is fast approaching when federal insurance regulation

needs to be put into place. PLEASE NOTE that I am not in favor of Unversal

Insurance Coverage. But insurance coverage vary state by state and you have

your hands full treating patients without having to try to figure out what BCBS

of Oregon requires in your patient care..., or which United Healthcare

subsidiary is in charge of the patient's plan you are treating. You can burn a

lot of unnecessary administrative time trying to figure things out or, our

United States Senators and Congressmen could push for standard laws and

coverages that make sense without running us all through the mill. Let's face

it, all insurance companies have their own ways and forms. If there were some

standards we could count on, things would be a lot easier and less time

consuming! Our reimbursement has been in a state of decline, but we are now

filling out more forms for insurance reimbursement and spending more time

chasing money. At what point does it make sense to draw the line in the sand

and take a stand?

Okay, off the soapbox now,

Jim <///><

Re: Out of state insurance plans

Hi Diane,

We are also having a problem with out of state BCBS. I am in NYC. The

reimbursment for a person who receives treatment here but has a home plan out of

state-particularly Illinois is REALLY low. There is no consistency at all. I

treat 2 people , both BCBS, both claims get sent to the SAME place. One has a

plan from Illinois and one from NJ and the reimbursement is vastly different.

And it is unacceptable in my mind. The people at BCBS frankly can't even explain

it to us!

a Meloe

>

> I operate a peds clinic in Massachusetts that provides OT,PT, and ST. We are

in-network providers for BCBSMA and are having consistent difficulty verifying

benefits for patients with BCBS plans from other states. Does anyone know if

there is a specific rule which determines which state's coverage policies apply?

Is it the state that the policy was written in or the state in which the

services are delivered? What about in circumstances where coverage is mandated

by state law, as with Autism services. Would love to hear other's experiences,

it is getting very difficult to explain to parents.

>

> Diane L. Maxson, MS, OTR?L

> Therapeutic Learning Center

> Canton, MA

>

[Guest guest]

I agree wholeheartedly Jim! The amount of admin time that we waste is

atrocious-not worth it in my mind. I am NOT a par provider for BCBS and I

shudder to think what they pay a par provider! Beth, the problem lies in the

fact that when we call to verify eligibility, we do call the home plan but they

do not explicitly tell us what the plans pays etc. Not sure how to get around

that. I am sure there is a way to ask them or verify what codes are covered???

Without having to submit a claim first.

I just went to Lobby in Wash DC while at the APTA convention and I also lobbied

for the NYPTA in May in Albany, NY and I can tell you that the our lobbyists

work REALLY hard for us. In the end, the insurance company lobbies have more

money to spread their influence around. But numbers are powerful-we had almost

1000 people at Lobby Day in DC and in NY we got our voices heard. Look at all

the support our California PT's are getting via FB and Twitter for the issue

with POPTS. I think that times are definitely changing and if we don't make our

voices heard via social media etc, nothing will ever get done. I think, for

what's it's worth, we are going back to cash practice. Old fashioned coincerge

medicine. Now I am off my soapbox now!!!

Thanks for the help everyone!!

a

> >

> > I operate a peds clinic in Massachusetts that provides OT,PT, and ST. We

are in-network providers for BCBSMA and are having consistent difficulty

verifying benefits for patients with BCBS plans from other states. Does anyone

know if there is a specific rule which determines which state's coverage

policies apply? Is it the state that the policy was written in or the state in

which the services are delivered? What about in circumstances where coverage is

mandated by state law, as with Autism services. Would love to hear other's

experiences, it is getting very difficult to explain to parents.

> >

> > Diane L. Maxson, MS, OTR?L

> > Therapeutic Learning Center

> > Canton, MA

> >

>

>

>

>

> ------------------------------------

>

> In ALL messages to PTManager you must identify yourself, your discipline and

your location or else your message will not be approved to send to the full

group.

>

> Physician Self Referal/Referral for Profit {POPTS} is a serious threat to our

professions. PTManager is not available to support POPTS-model practices. The

description of PTManager group includes the following:

> " PTManager believes in and supports Therapist-owned Therapy Practices ONLY "

> Messages relating to " how to set up a POPTS " will not be approved

>

> PTManager encourages participation in your professional association. Join

APTA, AOTA or ASHA and participate now!

>

> Follow Kovacek, PT on Facebook or Twitter.

> PTManager blog: http://ptmanager.posterous.com/

>