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Anthem Blue Cross Emergency Room Out Of Network Denial and A Solution

Posted Oct 25 2010 7:30am

Patients are frequently frustrated (as we your surgeons are) with emergency room work. Even when patients have insurance coverage, there are almost invariably delays and underpayment that thwart patient care.

Plastic surgeons already have an issue with emergency work. Many emergency room patients are without insurance and simply disappear when it comes time to pay the bill. It is bad enough that emergency work takes us away from our families at frequently ungodly hours.

I have had a few recent emergencies with Anthem Blue Cross patients in which the billing was a roller coaster. I am not a Blue Cross Provider and don’t want to be a Provider. The reason is simple. I don’t want to be bound to their rates for everything I do. Not being a Provider leaves me the option of billing the patient. I do not take emergency call because I like it. One of the hospitals that I use mandates that plastic surgeons take call. They don’t care that I live 50 miles away. At some point I may drop this hospital. I figure I should have the choice.

Nevertheless, one of my recent emergencies was in the evening on a Saturday. It involved a surfer who had burst open his scalp falling from his board. The surgery was somewhat involved and the bill to Anthem Blue Cross was around $2400. Two months later we received a letter from a negotiating company indicating that Blue Cross would pay $850 if I signed a statement that I would not bill the patient for any of the remainder. This was their “Take it or leave it” out of network negotiation.

My office called the patient telling him about the letter and that 35% of my bill was not acceptable. We gave him the opportunity to call his insurer to obtain a better reimbursement or we would simply bill him for the $2400.

The patient himself brokered a deal with Anthem Blue Cross and the bill was paid in the amount of $2100. We wrote off the $300. His point to the insurer was that in this emergency he was lucky to get a plastic surgeon and he could not control the fact that I was not a Provider.

The reason behind presenting this is to let you the client know that to Anthem or any insurance company you are the client. Your doctor’s office is just a vendor. Sometimes you have to pick up the phone and fight with your insurer to get the bill paid or be prepared to pay it yourself.

Best Regards,

John Di Saia MD

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