fully tore my rotator cuff, verified with my mri. insurance is denying surgery saying not medically necessary. cigna

Hi there,

I hope this post is okay, this is my first time here! I am an administrator working at a therapy practice. I am coming to you all with a question about your experience with the insurance carrier Blue Cross/Blue Shield (or on of their seemingly endless “home plans”)

Blue insured clients make up the majority of our demographic, however their plans are the most difficult to work with for the following reasons:

-Even when our claims indicate reimbursement should sent to us the provider, they are still sent to the client. Meaning for us to get paid for weekly sessions, the client has to pay us up front which sucks for them.

-With that, reimbursement amounts are constantly changing even when procedure codes, provider, timing, etc is all the same. This leads to constant account balancing.

-The member ID cards always instruct to submit to the local Blue plan. In NY, we submit to Empire. If there is another “local blue plan” that is somehow more local(???) in the past Blue has internally rerouted to achieve claim resolution. This past year they have simply denied claims instead, however they are never able to tell us which is the actual home plan to submit to. As you can imagine, with them taking 45 days to tell us this on one claim, only to have to try again and get the same result, has been so frustrating. To be honest I think this is actually what the MTA is suing them for right now in a multi billion dollar suit.

-It is virtually impossible to speak with a representative using any of the provider or behavioral health numbers on the member ID. Today I actually heard a new line in their automatic voice response system- they said that speaking with a live agent is not a possibility even before going through the prompts! This has never happened in my two years of verifying eligibility and benefits with them daily.

-I tried going through Availity instead to chat or get benefit information. Works spectacularly for other carriers, but the information for Blue clients is typically either dead wrong, or so confusing I have to call anyways. Availity now has not had any communication with Blue for two days and cite that they only display what is sent to them.

All this to ask- how do you guys do it? Is there a magical phone number that’s an industry secret where a helpful Blue rep can assist us? Is there another platform that can get us Blue benefit information where Blue themselves cannot and Availity cannot? How do you find the correct payer when there are tens of local plans per state with no indication on the card of which to use?

Feel free to take away my tinfoil hat, but at this point it almost seems intentional. No other carrier operates this way. Is it our out of network status?

Any info into your administrative/billing workings with Blue Cross, Blue Shield, or BCBS will be so appreciated to save this admin from going bananas. Thanks in advance either way, and always remember to take care of yourselves as you work to take care of others!