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  1. #16
    somarco is offline Member
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    We have to pay for services at the time of service
    and

    explanation of benefits it says "you need to request a refund from the provider
    What part of this do you not understand?
  2. #17
    justalayman is offline Senior Member
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    Quote Originally Posted by somarco
    Carriers do not have discounts.

    PPO networks (MCO's) are the ones who hold the contract with the provider.

    Inferences are fine but mean nothing, particularly in this case.

    Health Link has discharged THEIR liability when they paid the claim. This is now an issue between the patient and the provider.
    School me a bit on this one somarco, seriously. I want to understand this. It could eventually be me in this situation.

    I have BCBS. It is a ppo program. (Community Blue). When I have a disagreement with the payment of a bill, I contact BSBC,,directly. They have stated TO ME they have a contractual relationship with the PROVIDERS. So , either they are lying to me or there is a large misunderstanding in this situation.

    How is the OP's situation different?

    I still contend that if there is no ppo (or such) agreement betwen the OP's Dr. and the ins. (or mco) there should have been no "discount". In this case, the insurance company needs to revisit the billing to reflect the proper relationship beween them and the Dr.
  3. #18
    somarco is offline Member
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    MOST carriers do not have a direct relationship with a provider. This statement was qualified earlier. Blue is one of the exceptions. HMO's are another.

    Most other carriers do not have their own network but rather rent a network from companies such as PHCS, Beech Street, Great West and so forth. As such, there are no contracts directly between the carrier and the provider.

    In this case, the OP has indicated their carrier is Health Link. Perhaps this is another name for Blue in their area. Blue goes by different names in different areas. In some cases they are Anthem, Wellpoint, Unicare, Lumenos and other names. If Health Link is a Blue organization, then they may well contract directly with the provider.

    There is nothing to indicate there is a direct relationship between Health Link and the provicer.

    If Health Link is an HMO, then they may well contract with the provider. However, in this situation, it seems unlikely that Health Link is an HMO.

    The other issue, which really negates any influence the carrier has over the situation, is the fact the provider is not accepting assignment of benefits, is not billing the carrier, is not accepting payment from the carrier. Therefore the carrier does not have any means to enforce compliance with the negotiated fee structure.

    You & averad can continue to maintain it is the carriers responsibility to intervene but that does not make it so. The carrier has discharged their liability and made it known this is not their battle.

    And this . . .

    If the provider feared any repercussion from the carrier, they would have refunded the overcharge when requested. For what ever reason the provider feels they are immune to punitive action, especially from the carrier.

    In summary:

    1)The provider does not accept assignment of benefits.
    2) The provider does not bill carriers.
    3) The provider has refused to respond to requests from the patient to honor the fee schedule.
    4) The carrier has indicated they can do nothing
    5) This has continued for 8 months without resolution and most likely will continue in a stalemate unless a court awards a judgement in favor of the plaintiff
    6) This thread is way too long as Senior Judge offered a definitive response and that should have been the end.
    7) Beaufort, averad and you (layman) have ignored and/or misunderstood the facts and have kept this thread going with my help.
    8) I am now off the clock for this thread.
  4. #19
    justalayman is offline Senior Member
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    In this case, the OP has indicated their carrier is Health Link. Perhaps this is another name for Blue in their area. Blue goes by different names in different areas. In some cases they are Anthem, Wellpoint, Unicare, Lumenos and other names. If Health Link is a Blue organization, then they may well contract directly with the provider.
    Don't know if this applies or how it would affect the OP's situation but Healthlink and Healthpoint have merged with Anthem.(not sure it is the same Anthem as refereed to in this post)
    There is nothing to indicate there is a direct relationship between Health Link and the provider
    .True except the discount. It would seem the discount was improperly applied and the billing should have been treated as a non-provider or out-of-network provider and wasn't.


    The other issue, which really negates any influence the carrier has over the situation, is the fact the provider is not accepting assignment of benefits, is not billing the carrier, is not accepting payment from the carrier. Therefore the carrier does not have any means to enforce compliance with the negotiated fee structure.
    I totally agree, see answer above in this case.

    You & averad can continue to maintain it is the carriers responsibility to intervene but that does not make it so. The carrier has discharged their liability and made it known this is not their battle.
    I did not restrict my stand to a "carrier's responsibility". I also included what seems to be the situation. A improper EOB was issued that seemed to treat the provider as a preferred provider.


    1)The provider does not accept assignment of benefits
    .apparent
    2) The provider does not bill carriers
    .correct, as posted in original post
    3) The provider has refused to respond to requests from the patient to honor the fee schedule.
    correct
    4) The carrier has indicated they can do nothing
    correct
    5) This has continued for 8 months without resolution and most likely will continue in a stalemate unless a court awards a judgment in favor of the plaintiff
    very possible
    6) This thread is way too long as Senior Judge offered a definitive response and that should have been the end.
    believe it or not, there is not enough info to put it into a "sue them" category. The OP may be regulated by their agreement to others means prior and possibly excluding a lawsuit
    7) Beaufort, averad and you (layman) have ignored and/or misunderstood the facts and have kept this thread going with my help.
    NO, I have done none of the above. As I just stated, all the facts have not been presented to make a definitive ruling on the situation. Even you (somarco) have eluded to the possibility of your advice being wrong by acknowledging your ignorance as to a possible Health Link/ BCBS connection.
    8) I am now off the clock for this thread
    I wasn't aware anybody here was ever "on the clock" but your continued input was informative to me and I believe it to be germane to the OP's situation.

    I thank you for your time, patience, and information.
  5. #20
    averad is offline Member
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    Quote Originally Posted by somarco
    MOST carriers do not have a direct relationship with a provider. This statement was qualified earlier. Blue is one of the exceptions. HMO's are another.

    Most other carriers do not have their own network but rather rent a network from companies such as PHCS, Beech Street, Great West and so forth. As such, there are no contracts directly between the carrier and the provider.

    In this case, the OP has indicated their carrier is Health Link. Perhaps this is another name for Blue in their area. Blue goes by different names in different areas. In some cases they are Anthem, Wellpoint, Unicare, Lumenos and other names. If Health Link is a Blue organization, then they may well contract directly with the provider.

    There is nothing to indicate there is a direct relationship between Health Link and the provicer.

    If Health Link is an HMO, then they may well contract with the provider. However, in this situation, it seems unlikely that Health Link is an HMO.

    The other issue, which really negates any influence the carrier has over the situation, is the fact the provider is not accepting assignment of benefits, is not billing the carrier, is not accepting payment from the carrier. Therefore the carrier does not have any means to enforce compliance with the negotiated fee structure.

    You & averad can continue to maintain it is the carriers responsibility to intervene but that does not make it so. The carrier has discharged their liability and made it known this is not their battle.

    And this . . .

    If the provider feared any repercussion from the carrier, they would have refunded the overcharge when requested. For what ever reason the provider feels they are immune to punitive action, especially from the carrier.

    In summary:

    1)The provider does not accept assignment of benefits.
    2) The provider does not bill carriers.
    3) The provider has refused to respond to requests from the patient to honor the fee schedule.
    4) The carrier has indicated they can do nothing
    5) This has continued for 8 months without resolution and most likely will continue in a stalemate unless a court awards a judgement in favor of the plaintiff
    6) This thread is way too long as Senior Judge offered a definitive response and that should have been the end.
    7) Beaufort, averad and you (layman) have ignored and/or misunderstood the facts and have kept this thread going with my help.
    8) I am now off the clock for this thread.
    Health Link is a PPO and HMO provider [url]http://www.healthlink.com[/url]

    You_re making assumptions based on the OPs inability to understand their policy and eobs. As well even if the provider network is rented a contract exists and can be enforced. From what I read of the situation Health Link has not contacted the provider they only coached the member.

    You mention that if the provider feared the insurance carrier they would just refund the money. However if the Insurance carrier never contacts the provider or requests the money back why would the provider have anything to fear? Someone who is fluent with medical billing and Insurance payments should be talking with the provider especially with the member out $2,000.

    Quote Originally Posted by Craftmasters
    "you need to request a refund from the provider on the discounted amount. Be sure to make a copy of this EOB and send it in with your refund request"
    The Insurance carrier should not be placing this on their eobs if the provider is not contracted. This will confuse members and cause problems with providers.

    At this point it is best that the OP sues the provider for the money, I was commenting on the fact the insurance carrier should work for the member.

    The 20,000+ national members I directly manage hardly make me a layperson on this topic. They appreciate the hands on approach I and my team take to make sure our members are taken care of. Sure we could just wash our hands of their problems but, we try to take that extra step. I contact providers on a daily basis who are contracted or not to work out member issues.

    I bet this member is highly unsatisfied with this provider and the customer service at Health Link.

    Health Link is not a member of the BlueCross BlueShield Association.

    In the end
    Last edited by averad; 04-29-2006 at 12:03 PM.

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