Tearless and Fearless.Surviving the patient breakup. Blue Cross Blue Shield- you got some splainin’ to do!

It’s Friday afternoon. Tears of despair stream down my face. It’s funny, I never cried once throughout my entire breast cancer ordeal, when I was the patient- I guess because I had hope and faith then. For the first time in my professional career, a patient actually hung up on me.

The patient-physician relationship is unique, based on mutual trust and communication. It is like no other. I have countless such patient-physician relationships that span 20 years and four generations of many a family.

I have known the patient that broke up with me for two years, since I removed an advanced cataract from his eye and restored his vision to 20/20. At that time, I had “in-network” agreements with Medicare and Blue Cross/Blue Shield his secondary insurer. I severed all agreements with third party insurers last year. This year I saw him as an “out-of-network” provider. I performed a medically necessary laser procedure to improve his vision in my office in February, saw him in follow-up in March, and he was doing great.

Today he walked into my office angry and accosted my staff about an “Explanation of Benefits” he had gotten from Blue Cross/Blue Shield his secondary insurer. He made a scene in the office in front of my other patients and disparaged 4 wonderful women who work at my front desk. He was fed up and frustrated. He had filed with BCBS for out-of-network benefits with great frustration. Needless to say, after four different rejections and requests for more and different information each time, Blue Cross finally applied $275.00 to his deductible. He still did not understand the process and demanded a refund of $125.00.

Here’s the deal, he paid me a global fee of $400.00 for a complete examination, the laser surgery, and post op care. Had he used an “in-network” doctor and had the laser at an “in-network” facility the negotiated allowable would have been a surgeon’s fee of $275.00 and a facility fee for use of the laser of $700.00. He would have had to come out of pocket $415.00 after all was said and done. I actually saved him $15.00 and provided access and convenience. BCBS paid nothing.

Here’s the first sad part. Had he gone “in-network”, he still would have paid the $415.00, and BCBS would have had to pay the “in-network” facility $595.00. That extra $595.00 goes to a hospital or entity that owns the laser, and the extra expense results in higher premiums and so on for BCBS patients, and in the case of Medicare, it costs the taxpayers. In my situation, I bought the state of the art $25,000 laser and maintain it in my office-a facility I built and own. Yet, I charge no additional facility or laser fee, and it cost BCBS nothing. You would think BCBS would be thanking me for saving them $595.00 and encouraging such responsible business practice. But, then again, this is the age of Obamacare and MACRA.

Second sad part. I spent all afternoon trying to figure this out with BCBS. They will try to figure out their calamity of errs by the 15th via a conference call with multiple involved parties. The EOB they sent the patient told him I was an “in-network provider”. He thinks I deceived him. I have yet to see a copy of that. I notified BCBS in no uncertain terms, I was “out-of –network” last year, trust me. That’s another story in itself.

I called the patient to explain all this, and he said it was just too much of a mess to try to file with BCBS and although he liked me, it was not worth it, even if he saved money himself and saved money from being wasted by the dysfunctional healthcare system. As I tried to explain I was trying to do the responsible thing and create a new way that saved money and was better for patients and our flailing healthcare system, he just said he doesn’t care, he’s done, and hung up on me.

I blame BCBS for abusing my 71 year-old patient. BCBS intruded into a valid patient-physician relationship, undermined, and destroyed it. They lied to my patient. Ironically, I saved them $595.00. But, in reality, they have no idea what’s going on. What is happening to the other millions of patients they “insure?” How much money are they squandering?

My tears have dried up. I realize my breakup won’t be the last. He didn’t value our relationship or me as his physician and what I was trying to do for him- for all patients, for the economic viability of our country. He wants no hassles, at any cost.

What about BCBS? Well, they got some splainin’ to do. We’ll see what they say on the 15th.

Is BCBS really that inept and wasteful? Are they happy to pay off in-network facilities at the expense of patients and physicians? Or, could the patient harassment be intentional to punish the patient for going outside the network? Could this be an attempt to punish me for being “out-of-network” and put me out of business? What if the patient reports the fiasco to the state medical board? Then I will have to defend myself because of BCBS BS. It is becoming risky and hurtful to stay in medicine.

I will cowgirl up and carry on as long as I’m able. I pray for my former patient. I thank God for those who choose to understand the insane system and stay in my care. It will serve them well in the long run. I will fight the intruders in defense of the patient-physician relationship to my last breath- smiling, fearless, and tearless.

Happy Friday.

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3 thoughts on “Tearless and Fearless.Surviving the patient breakup. Blue Cross Blue Shield- you got some splainin’ to do!

  1. Give him time too cool down, then apologize for the inconvenience. I’m 71, a patient with a chronic condition, and when something seems to be going wrong, I blow up sometimes. Then, later I’m all apologies.

    I have Anthem in VA, I was an insurance agent for 25 years. Most likely, the claims people at BC/BS are used to filing all claims the same way. I know here, Anthem offers a plan that covers doctors who do not take medicare, and if medicare covers it, Anthem will cover it, even if the cost is higher. However, I know I would have to walk the claim through myself – but I know how the system works.

    Kudos to you for standing up to the system. Don’t give up.

  2. sometimes i cant help but wonder what is it about some people who are willing to stand up to what is clearly a much bigger enemy. Why do they fight a system that they have no chance of beating on their own. Why dont they just accept the status quo and abide by the rules that everyone else seems to try to squeeze under. I’ve come to realize that it is simply because it is who they are, and they must be that in spite of circumstances or outcome. These people are who fight evil and correct wrong at great personal sacrifice and for little recognition or reward. They do it because that is how they get to live their greater self, their true self. Kind of like Wonder Woman.

  3. Kris,
    Thanks for sharing this. This kind of payer shell game goes on all the time. And the paper pushers at the networks and insurers don’t have a clue… pawns like the patient. I think your alternate theory is correct: it is punishment, but more directed at us because our contract with payers is the only thing that holds the scheme together. If we didn’t have in-network agreements then the whole distinction goes away and they would have to re-write the EOB. As it stands now, patients and physicians are in kind of a prisoner’s dilemma .

    Like you line…”no hassles, at any cost”. That is kind of the inverse of a patient of mine whose son asked his Dad if he should just go with the higher priced provider so he would reach his deductible sooner. He received a nice southern “bless it, son”.

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