Blue Cross Blue Shield Health Insurance Review


Blue Cross Blue Shield Health insurance review: fees/rates, cost, medical claims, membership enrolling, in-network providers and out-of-network providers.



Overview


Health insurance, “you don’t need it until you do.” When most people purchase a health insurance policy, they are actually purchasing peace of mind. Reassurance that in the unfortunate event they are injured or become sick, that they are afforded the best medical care and don’t have to worry about a bill that could take years or even the rest of their lives to pay off. In addition, sick and injured people cannot contribute as they normally would to a society and they may actually create costs.

With this in mind, health insurance has often been the centerpiece in political debate as well; many changes have taken place within the last few years and it would seem that more many more on the way. At this time there are only a handful of major players in the US health insurance business. The top 5 based on number of enrolled members & revenue are: United Healthcare, Anthem Blue Cross Blue Shield, Aetna, Cigna, Humana.

Blue Cross Blue Shield began as Blue Cross in 1929 and is the 2nd largest health insurance company in the US with a reported 39.4 million members in early 2017.


Health network


BCBS offers domestic coverage in all 50 states and is accepted by more than 90% of doctors nationwide according to their website. This is achieved through a conglomerate of 36+ smaller, independent health insurers that pay a fee to license the trademark. They have an international health option as well through GeoBlue which merged with Bupa (a different international insurer) to create the largest international network available for travelers and people who are living outside of their native countries. According to the BCBS website the international network spans over 190 countries, 11,500 hospitals, and 750,000 physicians, impressive numbers to be sure.

When a provider is part of the health network that means that they agree to accept contracted rates from the insurer for their services and agree to bill the member as per the members own contract with the insurer. A provider can be in-network, out-of-network, or non-participating. The differences are listed below:

In-network providers: Must accept the contracted insurance rates for the services rendered and must bill the member in accordance with the specific health plan guidelines.

Out-of-network providers: Do not have to accept contracted rates for their services and can legally bill the remainder of a balance if they choose to do so.

Non-participating providers: Claims submitted by non-participating providers are not processed by the insurance company and the member is generally responsible for the full cost of treatment.


Blue Cross Shield Insurance Review


Membership features


BCBS members are provided with an ID card which are presented during medical visits and help providers file a claim correctly and efficiently. Members can register a portal account on their BCBS website which varies by state. The portal provides access to the member’s plan benefits, bill-pay services, ID card services, access to view claims (processing or processed), searching for in-network and out-of-network providers, among other features. All of these features can be provided or facilitated by a customer service representative as well. Customer service phone numbers & hours again vary by state; the general line is (888) 630-2583.


Enrolling


Signing up for plan can be done by calling customer service, calling an authorized insurance agent who can complete the process for you, through the website, filling out a paper application and mailing or faxing it in, or through the Healthcare Marketplace website (BCBS offers both on-Marketplace and off-Marketplace plans at this time). Quoting and enrollments can only be processed during the open enrollment period as put forth by the ACA regulations. More on open enrollment and special qualifying events here.


Medical claims


Claims are sent to BCBS by providers for processing via mail (varies by state) or electronic submission. According to BCBS guidelines, domestic claims are typically processed within 30 business days of their receipt and international claims within 60 business days. Once the claim has been processed, BCBS issues a letter and an EOB (explanation of benefits) that goes out to both the provider and the insured. The letter and EOB explain whether or not BCBS approved the claim, what steps should be taken next - if any, how much the provider will be paid according to the contact, and how much of the balance the member is responsible for. According to federal regulations set forth by the ACA, emergency visits to the emergency room whether domestic or international are processed as in-network claims and paid accordingly. Non-emergency international claims would only be covered under a GeoBlue international plan. More the ACA regulations regarding ER visits can be found here and more information on the GeoBlue program can be found here.


Blue Cross Blue Shield Health Insurance Review


Types of Plans


BCBS as with most of the major health insurers in the US offers: health coverage plans, dental coverage plans, vision coverage plans, and Medicare Advantage or Supplemental plans. These plans (excluding the Medicare Advantage or Supplemental) can be structured for individuals and families or group businesses. Group business accounts are split into small groups (<100 members and non-negotiable premium rates) and large groups (100+ members and negotiable premium rates). The health plans can be split into 4 categories: *PPO, *HMO,*EPO, and *POS.

- PPO plans offer both in-network and out of network coverage.
- HMO plans offer in-network coverage only within a localized area and require referrals from a primary care physician to see specialists.
- EPO plans offer in-network coverage over a large area, often spanning several states.
- POS plans offer in-work care and out-of-network care only.

The main components of a member’s health plan are the premium, deductible, out of pocket max, co-pay, and co-insurance. The premium is the monthly cost of the plan. Depending on how the plan is structured, a deductible is an amount that generally needs to met before the plan affords additional coverage. The out of pocket max is the total amount you will pay for any and all medical expenses, once the out of pocket max is reached the plan should cover 100% of additional costs. Co-pays are set amounts that the member should pay for a particular service; co-pays can apply or after deductible. Co-insurance amounts are responsibility splits for a balance at a percentage between the insurance company and the insurance member; co-insurance can apply before or after deductible but almost always does after.

Costs


BCBS plans are known to be some of the most comprehensive plans around and because of this they come with a hefty price tag. BCBS members can expect to pay upwards of 15%-20% higher premiums than the competition. At times the cost will outweigh the benefits when faced with a strong competitor such as United Healthcare or Aetna which offer similar plans at a lower premium rate. After the ACA was implemented BCBS has also become notorious for premium rate hikes for both individual / family plans and employer groups, with some rate increases being recorded anywhere from 20% to 60% on a yearly basis! Some examples of BCBS rate hikes can be found here, here, and here.


Recent news


BCBS has partnered with Lyft to provide transportation to medical appointments for members at no additional cost as of this time.


Known issues


Members report that claims on the BCBS portal do not detail what services were rendered or why a claim was processed a certain way. They report that auto-draft information is sometimes removed or the monthly payment fails to go through due to what BCBS refers to as technical difficulties or for other unknown reasons. And when complex issues are reported to BCBS, a ticket is opened for someone to be assigned and work the file. Instead customers call back to find the ticket was never worked on or closed out. Here is the most recent example of a widespread billing issue and here are consumer complaint reports about BCBS.


In summary


BCBS offers plans that provide members with the most comprehensive coverage available on the market. However they come at a higher cost than the closest competition. In addition BCBS has a poor claims system, seems to have billing problems often, and seems to be inefficient when it comes to problem resolution. Until BCBS cleans up their act, unless a consumer is looking for the best coverage and the best coverage only, it’s best to look elsewhere.


Updated on 6/1/2017.



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