Primary Care Visit Questions

I have Keystone Health Plan East HMO (Independence Blue Cross plan) insurance and have a primary practice group designated as required. I have an issue that I don’t think is correct. It’s impossible to talk to anyone helpful at IBX – the call center employees can’t help. I’m going give the practices fictional names to make it easier.

My old primary care practice group (Dr Family Med) was in network with KHPE and any provider (DO, NP,etc) I saw there processed as a primary visit.

I have been with a new group for over a year. Let’s call them (ABC primary care). I really like the providers and have had really great treatment. But for some of the providers they bill under a different group (XYZ primary care) (I.e – NPI of a different group/different office location that I was NOT seen at)

Their post billing customer service says it’s because of a credentialing problem by IBX that some providers have to bill under that other primary group. It means the claim processes with a higher specialist copay – double the cost for me even though it’s a primary care visit.

So I call ABC to make an appointment at ABCs location, but the bill is submitted as XYZ. And of course the appointment schedulers, front desk and MAs entering notes always say “You are seeing ABC”. I have claims going back to Jan that they rebill but nothing changes and as of last month it is still happening.

I’ve sent two letters to KHPE at their appeals PO Box since June and had no response.

How do you escalate with them to actually speak to someone locally as a member with this problem? I think they need to tell the doctors office that they are wrong because the doctors office blames the insurance.