Blue Cross out-of-network costs rising

By Bruce Japsen
Posted Feb. 24 at 11:23 a.m.

Blue Cross and Blue Shield of Illinois health plan members are facing higher out-of-pocket costs if they see a physician not in the health plan’s network under a new doctor payment system being rolled out by its parent company.

Chicago-based Health Care Service Corp., the nation’s fourth-largest health plan, has begun basing its doctor fee schedules on the lower rates paid by the Medicare health insurance plan for the elderly. Exactly how much more a patient will pay for out-of-network will vary. But the AMA said Medicare rates are often 20 percent below the cost of providing medical-care.

The national average of a typical visit to a doctor by an “established” patient is $87, resulting in the consumer paying $43.50, according to an AMA analysis of large private health plans. A patient could end up paying $50 or more, an increase of at least 14 percent, AMA figures provided to the Tribune show. Because Medicare rates vary across the country, that amount would depend on where the patient lives.

The move has rankled doctor groups who say they are already getting squeezed by health insurance companies. And because they are getting paid lower rates for out-of-network services, that will shift more of the medical bill burden on hundreds of thousands of patients nationally.

“Patients enrolled in preferred provider organizations offered by Health Care Service Corp. need to closely review their benefit plan to determine if the insurer’s new out-of-network payment policy will result in a cut in benefits,” said Dr. James Rohack, immediate past president of the American Medical Association and a cardiologist from Texas.

“The more the out-of-network benefit is reduced, the less flexibility patients have to choose a physician from outside the insurer’s network. For some patients, out-of-network care may become unaffordable.”

So-called PPOs are the most popular form of health insurance in that they allow patients to leave the health plan’s network, or preferred list of medical care providers for care unlike HMOs that restrict choices of doctors and hospitals to their networks. PPO patients who leave the network have always faced higher costs but now they will rise more.

“By underpaying medical bills, insurers often shift blame to physicians and undermine relationships between patients and physcians,” Rohack said.

Health Care Service said the change is being made in the name of “transparency” for medical care providers at a time doctors and insurers are working toward implementation of the health care overhaul.

“Medicare is the most widely accepted level of reimbursement nationally and recognized by many providers, regulatory bodies and others as a national standard,” Health Care Service said in a statement to the Tribune. “As a result, we expect this methodology to increase transparency for providers and members through availability of information about Medicare standards.”

Health Care Service says only 3 percent of its PPO health plan members use physicians not in their health plan networks. Health Care Service provides benefits for 12.7 million people, including 6.7 million in Illinois.


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  1. 007 Feb. 24 at 12:29 pm

    They’re rising in-network too. I have a yearly test done in February and this year my out-of-pocket costs were $200 more despite my having the same group policy, same procedure, same doctor, same facility, same patient, same result, and same amount billed.

    Thank you health-care “reform” for costing me more money.

  2. Rance Spergl Feb. 24 at 12:40 pm

    @007: your ignorance is on parade for all to see. Obviously you’re just a hater.

    Everyone knows, except you it seems, that the new health care law doesn’t fully come into effect until 2014. We all know this, it’s been publicized for the last 2 years. What you’re experiencing is the insurance company continuing to bilk you for escalating costs. That’s what the free market gets to do if it wishes, it can charge you more because it feels like it. Usually to pay the CEO and shareholders more, not to increase the quality of your care or to lower cost.

    So suck it up 007, once again you’ve been had by capitalism. Good luck with that.

  3. George Feb. 24 at 12:45 pm

    @007 Have you called your insurance and asked why?

  4. Pussy Galore Feb. 24 at 12:46 pm

    007, your cost increased because your employer raised your co-insurance level. remember, patient out of pocket cost are detemine by the level of benefits your employer purchase. your employer determines how much they wlll cover and how much you will cover. recently employers have gone from a 90/10 sharing structure to a 80/20 structure, to reduce the price of the premium your employer pays.

  5. Publicus Feb. 24 at 12:49 pm

    Just another reason to implement a single provider health care system. Eliminate the health insurers – the billions saved in claims administration costs and insurer claims denial policies will more than cover any rise in medical costs. But that would deprive the Republican corporatists of egregious profits – and deprive all of the right-wing and libertarian ideologues of an opportunity to rant about “big government.”

  6. Dave Feb. 24 at 12:54 pm

    Rance – since capitalism and the insurance companies are so evil, why even buy insurance? Take your luck with just going to the doctor without any coverage and see what you pay if they will even see you.

  7. Rance Spergl Feb. 24 at 12:59 pm

    @Dave: another commenter with mental deficit disorder.

    That, Dave, is why we want single payer health care. Because insurance companies are the spawn of Satan, Dave, and have no place in a free society. They are asking you gamble on your health and enrich their CEO while you’re at it. It was a stupid idea then, it’s a stupid idea now.

    Dave, please come back and participate when you’ve learned something about how the world works.

  8. m Feb. 24 at 1:06 pm

    Thanks POTUS!

  9. Terrence Phillip Feb. 24 at 1:17 pm

    I perform my own shots and surguries. I went to CPS, so you know I’m the goods.

  10. Morgan Feb. 24 at 1:19 pm

    Just fly out to India for all your medical needs.

  11. Alex Feb. 24 at 1:22 pm

    “Everyone knows, except you it seems, that the new health care law doesn’t fully come into effect until 2014. We all know this, it’s been publicized for the last 2 years. What you’re experiencing is the insurance company continuing to bilk you for escalating costs. That’s what the free market gets to do if it wishes, it can charge you more because it feels like it. Usually to pay the CEO and shareholders more, not to increase the quality of your care or to lower cost.”

    Partly true. Some provisions HAVE been put into effect and are costing people money. The HSA provision in the bill is one that really ticks me off.

  12. fb Feb. 24 at 1:26 pm

    Rance, if I had the ability to shop around for my health insurance, like I’m able to do with almost everything else I buy including my life insurance, I’d be able to use the free market system to buy a less expensive plan while still providing my family with the same coverage. As it stands, and something the current Congress and POTUS didn’t change, I can’t go outside my state for health insurance. That severely limits my options to purchase the best plan for my family.

    When I recently shopped for life insurance, I checked with the offerings from my company and about a dozen other companies throughout the country. I compared costs and insurance levels and picked a plan that offered the best cost/coverage ratio. I can’t do that with health insurance, therefore it is not truly a free-market system. The pressure to compete on prices with hundreds of other companies offering similar products always results in lower costs to consumers.

  13. Peter Smith Feb. 24 at 1:29 pm

    Rance, I’ve seen what happens in single payer health care. One of the Canadians I know works for their border patrol agency. On the job, he slipped on a patch of ice and wrenched his knee. He followed all of the rules, all of the instructions from the hospital and doctor, and was given two choices: wait nine months for an MRI, or take a voucher and go to an American hospital and have the MRI done there. Since he lives in a border area he chose the second option and had it done in the same week. If he wasn’t able to cross the border, he would have been stuck waiting the nine months.

    Compare that to when I slipped on some ice and fractured my ankle. I went to my doctor’s office the next day (a Friday, which was a delay that was self-imposed because I thought it was just a sprain), was x-rayed an hour after my visit, and splinted for the weekend until I could see the specialist on Monday. X-rayed again to get the images into their system, and in a boot about an hour after the second visit started.

    Now you tell me why people like me would prefer not having a single payor system.

  14. Miles Feb. 24 at 2:09 pm

    This is why Obama wants the healtchcare bill so that ALL people will have healthcare at lower rates.

    Don’t respond with your silly remarks that you pull out of your butt.

    Conservies that are talk show hosts, I assure you, have totally free medical. It’s in their contract!!!!

    The insurance companies would of raised premiums regardless….

  15. ctrib61074 Feb. 24 at 2:33 pm

    I find it hard to comprehend why health providers would not belong to the insurance companies plan(s). The rates are somewhat reduced, but the volume of patients should more than make up for any losses. I believe most health care providers do belong to one of the BCBS plans…at least they do in my area. Finding a health care provider who can provide me with adequate health care has never been a problem for me. As for the charged rates, just look around….everything is going up in price !!!

  16. fb Feb. 24 at 2:45 pm

    Miles, you provided absolutely no value to this discussion. Please provide some facts that support how healthcare costs will go down. Someone has to pay. I also doubt that any talk show host has free health care. In the end SOMEONE has to pay, nothing is free.

  17. spellin' Feb. 24 at 3:06 pm

    Ha! Their out of pocket expenses are definitely up for in network as well. I will not say what I think the BS is BC/BS stands for.

  18. MinisterR Feb. 24 at 3:15 pm

    read any post on nay trib forums by rance and you can decide who is the hater him or just everyone who disagrees with him.

    He is the biggest cr ap talker and racist on these boards

  19. Wayne Feb. 24 at 3:37 pm

    As far as your rant about shareholders, I guess that you are unaware that BCBS of Illinois is NOT a shareholder owned company. And as for the health care bill not having any impact on rates this year, I guess you don’t realizet that the mandatory coverage of children till age 26 went into effect on Jan 1 2011, and has been one of the major drivers of cost increases.

  20. emmybee Feb. 24 at 4:00 pm

    BCBS has to come up with the $25 million that they have to pay the state of Illinois for defrauding the state and consumers. That money has to come from somewhere. They are raising everyone’s deductibles, co-pays and co-insurance and premiums.

  21. emmybee Feb. 24 at 4:04 pm

    “CHICAGO (Crain’s)—Blue Cross Blue Shield of Illinois agreed to pay $25 million to settle state and federal claims that the insurance company knowingly denied coverage for a decade to sick kids.

    The deal, in which Blue Cross Blue Shield does not admit any wrongdoing, was announced Thursday by the Illinois attorney general’s office and the U.S. attorney’s office. The firm reached the agreement to avoid a lengthy and costly court process, according to the settlement document.

    The state of Illinois will receive $15.5 million in the settlement, with the remaining $9.5 million going to the United States.”

    Notice none of this money is going to consumers who had to pay because they were denied coverage.

  22. 007 Feb. 25 at 8:23 a.m.

    Rance, your ignorance is showing. And usually when the first response to a post is to be called a hater, that shows that I won the argument and the poster has nothing concrete to offer. But I can’t resist.

    Insurers are raising premiums and copays like crazy now because Madame Pelosi’s new bill ALLOWS them to do so, to compensate them for the caps that will be in place when the changes are fully in effect. And parts of “reform” are in action now, like having to cover “kids” up to age 26 on Mommy and Daddy’s policy.

    I hear they’re going to open some new Wal-Marts in the city. Perhaps you should stock up on clues when they do. It’s obvious you don’t have access to any now.

  23. YuanChingLee Feb. 25 at 6:20 pm

    BCBS is a soul-less organization which I have no respect for. I hate the government take-over of health care, but I hate BCBS more… that says a lot. Avoid BCBS at (& for) “all costs” if you can!