Anyone work for BCBS/LA insurance? Help!
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re: Anyone work for BCBS/LA insurance? Help!
Posted by VeniVidiVici on 5/23 at 9:35 am to drunkenpunkin
Punkin, I just FW some emails to you from people I know in the business. Hope they help.

Most have repeated ideas already posted here.

Take care and keep us updated!



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Posted by ThatsAFactJack on 5/23 at 9:35 am to drunkenpunkin
quote:

drunkenpunkin
quote:

Thank you all! Driving to work (hour away). But I will check back in. I can't thank y'all enough. My email: tdpunkin@gmail.com if anyone needs it. I appreciate y'all SO much!


Drunkenpunkin, I sent you an email. With my job I have several contacts/connections with higher ups at BCBS. I sent you one contact that should be very helpful.

Best of luck.



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Posted by iluvdatiger on 5/23 at 9:43 am to drunkenpunkin
From march bcbsla news letter:
Recently, the Food and Drug Administration (FDA) has placed increased scrutiny on the practice of compounding drugs and their uses. Blue Cross and Blue Shield of Louisiana has also reviewed our members' compounded prescription drug claims.
The results confirmed many compound prescriptions are being used for a purpose that has not been properly studied and has not been FDA-approved. These findings have led us to more closely examine our coverage of compound prescriptions.
How this affects your clients:

Effective May 1, 2013, we will no longer automatically cover each prescription written for compound drugs. We will scrutinize some of these prescriptions more closely. We expect 75% of compound drug claims to process automatically and pay just as they do today without restriction.

Members have the right to appeal if their compound drug prescription is not covered at the pharmacy. We will base appeal decisions on contract language that is already included in the member's benefit plan.

If a member chooses to take a compound drugexcluded from coverage, he or she will be responsible for the entire cost of the compound drug.

This change affects fully insured groups and individual members. Self-insured groups may opt in for this additional scrutiny at no extra charge if they contract with Express Scripts through Blue Cross.

How will we tell members and providers about this change?

We will send a letter to members, who have recently filled a prescription for a compound drug, encouraging them discuss the changes and their options with their doctors. Additionally, we will send notification letters about these changes to doctors who have prescribed compound medications.



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Posted by Sgt_Hulka on 5/23 at 9:56 am to drunkenpunkin
Not sure if this has been mentioned in the thread... but you need to check with BCBSLA about MTM - Medical Therapy Management and have a case manager assigned. Once you get that, then you can ensure a Nurse and Doctor will review your son's case and condition. Not only will this fast-track any appeals process, it generally eliminates the need to have claims rejected unnecessarily (as the case seems to fit that description).

Also, request specifically to talk to Allison Young -- she's pretty good at addressing customer complaints.

All that said, it does sound like you are not fully versed in your policy. My suggestion, read it several times and become an expert on it. Most people neglect to actually see what they are paying for, and then complain when they find out that after years of paying for a specific policy, it doesn't solve all the world's medical problems.



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Posted by hehateme2285 on 5/23 at 10:02 am to VeniVidiVici
quote:

She can appeal a non-covered benefit through an administrative appeal, everyone has appeal rights. Usually all it takes a formal letter from the member saying they want to appeal and getting their doctor involved as well. The doctor can actually request a peer to peer talk with BCBSLA medical directors and have a discussion about the issue as well.


You have to do this. You have rights to an appeal with BCBS, as well as an independent third party review. I'm currently going through this. Get your doctor involved with formal letters as well



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Posted by Sgt_Hulka on 5/23 at 10:04 am to TigerTattle
quote:

Makes me wonder if the B flagged my name.


Ummm... as a former employee of BCBSLA, and several other Health Insurance companies... I can assure you that this does not happen.

Customer service does NOT have any magic button "This patient is uncooperative." or anything like that.

Now, if you were trying to get a claim processed for a narcotic, yes -- customer service agents are generally trained to flag a claim and/or patient for possible fraud or drug abuse. Those flags send that patients claim history to an audit department for review.

Other than that, your name doesn't get flagged for simply being an unpleasant customer. No matter how much a pain in the arse you are (or they think you are).



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Posted by saderade on 5/23 at 10:06 am to Sgt_Hulka
This has been a recent trend with insurance companies and compound medicines. They basically don't want to pay for it and think that a percentage of people will never appeal


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Posted by iluvdatiger on 5/23 at 10:28 am to saderade
Not many people can afford the actual cost of a lot of these drugs that are being moved up a catagory or are no longer covered. In the case of the cancer patient with the Neupogen:
Drug cost-$7200
Bcbs allowed-$5222
Cat 4 copay-$100
Now that it isn't covered any longer and there is no generic equivalent, I guess the woman either pays the full cost for the drug or just dies!



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Posted by Sgt_Hulka on 5/23 at 10:31 am to saderade
quote:

This has been a recent trend with insurance companies and compound medicines. They basically don't want to pay for it and think that a percentage of people will never appeal


It is a recent trend, yes. But the trend isn't with insurance companies. It is with the compounding companies themselves. They have been mixing and matching drugs into "compounds" for years, but lately they have been doing it at an alarming unsafe rate. The FDA has issued quite a bit of guidance and actions against the compound companies lately. The insurance companies are just reacting to the market - their policies and actuarial practices take into consideration of individual drugs getting prescribed and paying certain number of claims. The compound drugs, when not medically necessary, are simply compounded to save the consumer money. Say you have 5 drugs a patient needs - typically, that is a claim with a copay for each drug, right? Well, if the patient buys those from a compound company, it potentially saves the patient 4 copays per month. If the copay is $10, that's a savings of $40 per month for the patient, but a loss of revenue for that same amount to the insurance company. The insurance companies count on the copays as income. The patient has actually cheated the insurance company. The problem is, there are still countless times when the compounding is legit -- so who should burden the cost of evaluating each of these cases? The consumer doesn't want to do it. The compound drug providers sure as hell won't do it. So that leaves the insurance companies themselves to do it.

As shitty as it seems, the most practical and lowest impact to the consumer is to reject the majority of the claims based on the NDC's (national drug code) in the compound. If they just pay all compounds that are submitted, ALL consumers will get hit with higher premiums to cover the cost of lost copays. So, really, the best way to handle it all around is the way the are doing. Unfortunately, it does mean that a lot of medical necessity claims are rejected on first pass. FORTUNATELY, the consumer does have the right to an appeals process.



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Posted by Sgt_Hulka on 5/23 at 10:35 am to iluvdatiger
quote:

ot many people can afford the actual cost of a lot of these drugs that are being moved up a catagory or are no longer covered. In the case of the cancer patient with the Neupogen:
Drug cost-$7200
Bcbs allowed-$5222
Cat 4 copay-$100
Now that it isn't covered any longer and there is no generic equivalent, I guess the woman either pays the full cost for the drug or just dies!



No, that patient needs to actually appeal to AmGen's assistance program. Almost all pharmaceutical companies offer assistance programs for uninsured and under-insured patients.




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Posted by Breadcrumbs on 5/23 at 10:52 am to drunkenpunkin
there are 3rd party medical mediation companies that resolve issues with insurance companies. Not sure of how to contract with them or their costs.

good luck and persevere. it's worth the fight.



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