Blue Cross Blue Shield

Question

Answer

My comment to that is welcome to the club. Blue Cross Blue Shield plays a game. Here's how the game works. Blue Cross says that "We will cover hearing services." Now, that sounds really good, doesn't it? But the caveat is "We will cover hearing services, only if they are provided by a medical doctor. If the hearing services are provided by someone who is not a medical doctor, we will not cover them, on the basis of the qualifications of the provider of those services."

Here is my own personal example. I have a Blue Cross provider number for Florida. If I receive a patient and I bill Blue Cross, I am denied because of who I am. If a physician with an MD bills the same services, they will pay. We've had conversations with them, but to no avail. And Blue Cross tends to play this game in virtually every state, to some extent to another. If they don't play this game, you're the exception and not the rule, and you are very fortunate.

Evidently, Blue Cross and Medicare are combined now for some groups. Because of the change we have not received reimbursement from Blues for patients under this plan for several weeks. No one seems to know why, whether it's an EDI issue or our NPI numbers, etcetera.

Medicare and the Blues are combined in many states. That does not mean that they are one. What this refers to is that Medicare, in most states, has contracted with a local insurance carrier within that state to be the intermediary between the provider and Medicare.

Many times, the carrier is a subsidiary of Blue Cross Blue Shield. For example, in Connecticut and Florida, First Coast is the carrier for Medicare services in both of those states. Empire, in New York, is the carrier there. And I'm not sure what it is in other states, but most often, it's quite common for that carrier to be either a Blues or a subsidiary of the Blues.

Now, if you're not getting paid and you were previously, then what I suggest is to call the provider liaison and have that person help track down for you what the issue is why you're not getting paid, because, with your contract as a provider with that payer, they are obligated to make sure that everything is appropriate, that everything is fair, within the definition of the contract, to both sides.

So call the provider liaison. That person is found at that carrier's headquarters within your state. When you call them, you'll get a general number. Say, "I'm an audiologist. I want to talk to the provider liaison about some issues regarding submission of payment of services." You also need to check to make sure that they have your NPI number cross-referenced with your old provider number and make sure everything's straight there.


Robert Fifer, Ph.D., is the Director of Audiology and Speech-Language Pathology for the Mailman Center for Child Development at the University of Miami School of Medicine. He is also an Audiology Online Contributing Editor in the area of Coding and Billing. He is the ASHA representative to the American Medical Association's Health Care Professions Advisory Committee for the Relative Value Utilization Committee in addition to being ASHA's representative to the AMA's Practice Expense Advisory Committee.

Editor's Note - The above is a partial transcript from the Coding and Billing QNA Live e-Seminar that was conducted on Audiology Online on June 27, 2007. (The recorded version is available here - Also the complete edited transcript is available here. The format of the session was different from most traditional presentations as we solicited questions ahead of time and also solicited questions during the event and had Dr. Fifer focus on answering those questions during the live session. We have published the transcript from the seminar in a semi-rough format to preserve the live feel from the session and to accelerate the publication timeline of this information to the Audiology Online readers. Submitted questions are bolded, followed by Dr. Fifer's response. Dr. Fifer is a frequent Contributing Editor for Audiology Online in this area, look for additional Coding and Billing QNA sessions on our home page in the near future. - Paul Dybala, Ph.D. - Editor