Provider is out-of-network for the new BCBS insurance; should we just do self-pay for the upcoming office visit?

Hi everyone,

My relatives recently moved states and now have new BCBS-affiliated marketplace-subsidized health insurance in NC. This insurance is tied to a large local health system and everything that is NOT in that alliance (and not an emergency) is treated out-of-network with unlimited OOP max and separate large deductibles.

They used to have a BCBS-affiliated plan in the old state AND they both had their great doctors in that state. They plan on visiting their “old” doctors at least once again soon and then transfer their files to some new doctors in NC that are yet to be found.

I am a little worried about the coverage for these visits, but so far I was getting some conflicted information from their new plan and from the OLD health system/doctors’ offices. Basically, there are the options I see:

They can do self-pay for the upcoming visits without even showing their new NC insurance (as it will probably not cover almost anything due to a large OON deductible). When I asked the provider’s offices about self-pay, they mentioned an amount in the ballpark of $150-200 per visit if no extra imaging / expensive procedures are required.

They can present their NC BCBS insurance and then wait for the claim to be processed. And here comes a somewhat murky part. I’ve been told by the doctor’s office that normally they send claims like this to the local affiliate of BCBS for processing. Whoever processes this claim will probably figure out the provider is OON for their current BCBS NC plan and below the deductible and will cover nothing, so the bill will become my relatives’ responsibility.

What I don’t know and cannot find out is if BCBS would still adjust the bill to some reasonable amount AND, given the provider is OON, the provider would actually honor this adjustment and pass it on to the patient.

Back when they had BCBS in the old state, I’ve seen some claims the following way: the provider charge was $715.00 for a visit, non-billable amount was almost $600.00 under J1150 code (“J1150 – This is the difference between the provider’s charge and our allowance. You are not responsible for this amount.”) and the final charge was around $115.00.

Obviously $115 is less than $200, so they would love to just be able to pay $115 and call it a day. However, what I want to avoid at all costs is for them to get hooked on $715.00 charges!!!. And I had a somewhat similar experience with one of the labs a few years ago that was of the very similar origin – lab billed an exorbitant rate for a simple test, insurance denied coverage entirely under “test not covered for this age group” and the lab tried to charge me that original exorbitant charge, even though a self-pay for that test was probably ~20% of that original charge, BUT their explanation was “you had to opt-in to self-pay right away, we cannot switch to self-pay now when we already submitted it to the insurance”.

Any advice? Should I contact doctors’ offices billing departments or they would be of no help? I reached out to BCBS NC and after a similar explanation the only thing they told me was that the OON provider is usually under no obligation to honor any adjustments from an insurance carrier they have no contractual relationship with.

I am personally inclined with “just do self-pay” route, but wonder if I miss something… Thanks a lot!