Chapter 13 Blue Cross and Blue Shield Plans

Introduction • Blue Cross and Blue Shield – Perhaps the best known plans of

Origin of Blue Cross • Blue Cross, 1929 – Baylor University hospital in Dallas, Texas – Offered teachers in the Dallas school district a plan of twenty-one days of hospitalization every year for the holder and their dependents in exchange for $6 annual premium 3 Copyright © 2008 Delmar Learning. All rights reserved.

Origin of Blue Shield • “Began as a resolution passed by the House of Delegates at an American Medical Associations meeting in 1938. Resolution supported the concept of voluntary health insurance that would encourage physicians to cooperate with prepaid health care plans. ” 4 Copyright © 2008 Delmar Learning. All rights reserved.

Joint Ventures • Blue Cross originally covered only hospital bills – Blue Shield only covered fees for physician services – Over the years Blue Cross and Blue Shield have increased their coverage to include almost all health care services 5 Copyright © 2008 Delmar Learning. All rights reserved.

BCBS Corporation • Submit insurance claims for all BCBS subscribers • Provide access to the Provider Relations Department – Assists PAR provider in resolving claims or payment problems 6 Copyright © 2008 Delmar Learning. All rights reserved.

BCBS Corporation • Write off the difference or balance between the amount charged by the provider and approved fee established by the insurer • Bill patients for only the deductible and copay/coinsurance amounts that are based on BCBS-allowed fees 7 Copyright © 2008 Delmar Learning. All rights reserved.

BCBS Corporation • In return, BCBS corporations agree to: – Make direct payments to PARs – Conduct regular training sessions for PAR billing staff 8 Copyright © 2008 Delmar Learning. All rights reserved.

BCBS Corporation • Provide free billing manuals and PAR newsletters • Maintain a provider representative department to assist with billing/payment problems • Publish the name, address, and specialty of all PARs in a directory distributed to BCBS subscribers and PARs 9 Copyright © 2008 Delmar Learning. All rights reserved.

Plans • Blue Cross Blue Shield coverage includes the following programs: – Fee-for-service –

Plans • Managed care plans – Coordinated home health and hospice care – Exclusive provider organization – Health maintenance organization – Outpatient pretreatment authorization plan – Point-of-services plan – Preferred provider opinion – Second surgical opinion 11 Copyright © 2008 Delmar Learning. All rights reserved.

Plans • Federal Employee Program • Medicare supplemental plans • Healthcare Anywhere 12 Copyright

Fee-for-Service • Fee-for-service is selected by two different kinds of people: – Individuals who do not have access to a group plan – Small business employers 13 Copyright © 2008 Delmar Learning. All rights reserved.

Fee-for-Service • Those two contracts have two different coverages within one policy: – Basic

Fee-for-Service • BCBS basic coverage routinely includes the following services: – Hospitalizations – Diagnostic laboratory services – X-rays – Surgical fees 15 Copyright © 2008 Delmar Learning. All rights reserved.

Fee-for-Service • • • Assistant surgeon fees Obstetric care Intensive care Newborn care Chemotherapy

Fee-for-Service • BCBS major medical coverage includes the following in addition to the basic: – Office visits – Outpatient nonsurgical treatment – Physical and occupational therapy 17 Copyright © 2008 Delmar Learning. All rights reserved.

Fee-for-Service • • • Purchase of durable medical equipment Mental health visits Allergy testing and injections Prescription drugs Private duty nursing Dental care required as a result of a covered accidental injury 18 Copyright © 2008 Delmar Learning. All rights reserved.

Billing Notes • Claims processing: – BCBS plans process their own claims • Deadline for filing claims: – Customarily once year from the date of service, unless specified • Forms used: – Most BCBS currently accept CMS-1500 claim 19 Copyright © 2008 Delmar Learning. All rights reserved.

Billing Notes • Inpatient and outpatient coverage: – Many plans require second surgical opinions and prior authorization for elective hospitalizations 20 Copyright © 2008 Delmar Learning. All rights reserved.

Billing Notes • Deductible: – Look up in the billing manual or call the

Billing Notes • Copayment/Coinsurance: – Most common coinsurance amounts are 20 percent and 25 percent – Some may go as high as 50 percent for mental health services • Assignment of benefits: – Payment is made directly to the provider by BCBS 22 Copyright © 2008 Delmar Learning. All rights reserved.

Special Handing • Make a habit and priority to have a current copy of the front and back of all patient ID cards in the patient’s file • Patients with Blue Cross who have more then one insurance policy – Must be billed directly to the plan from which the program originated 23 Copyright © 2008 Delmar Learning. All rights reserved.

Special Handing • Non. PARs must bill the patient’s plan for all nonnational account patients with Blue. Cards • Rebill claims not paid within 30 days • Some mental health claims are forwarded to a third-party administrator 24 Copyright © 2008 Delmar Learning. All rights reserved.

Primary Claim Status Is Determined When • Covered by only one BCBS policy • Covered by both a governmentsponsored plan and employersponsored BCBS plan • Covered by a non-BCBS plan that is not employer-sponsored 25 Copyright © 2008 Delmar Learning. All rights reserved.

Primary Claim Status Is Determined When • Designated as the policyholder of one employer-sponsored plan and also listed as a dependent on another employersponsored plan. 26 Copyright © 2008 Delmar Learning. All rights reserved.

Secondary Coverage • Modifications are made to the CMS-1500 claim when patients are covered by primary and secondary or supplemental health plans. 27 Copyright © 2008 Delmar Learning. All rights reserved.

When Completing BCBS CMS-1500 Claims • • Block 12 - Enter signature on file Block 19 - Leave Blank Block 20 - Enter an X in the NO box Block 23 - Leave blank 28 Copyright © 2008 Delmar Learning. All rights reserved.

When Completing BCBS CMS-1500 Claims • Block 26 - Enter the patient’s account number • Block 27 - Enter an X in the YES box • Block 31 - Enter the provider’s complete name with credentials 29 Copyright © 2008 Delmar Learning. All rights reserved.