BCBS FEP Co-Pays

forgve70x7 · January 3, 2008

So, I had my surgery in July which thankfully was covered by insurance. They also cover my fills, and I'm wondering if anyone out there is having to pay a Surgery Co-Pay for their fills. When the dr's office initially called to get the approvals they were told that my fills would be $30, but when I got my EOB's they said that a fill is considered a surgery.

I am planning on appealing this (mostly because it costs me about $300 when I travel for my fills), but was wondering if anyone has had any other problems with this same issue.

Looking forward to hearing from you,

~Nichole

Pizzaman · January 5, 2008

I'm getting banded Thursday courtesy of BC BS FEP, so I'll have an answer for you in a couple of months. But I find it hard to believe that a fill at a doctor's office usually done by a PA could be categorized as "surgery."

cheri52 · January 6, 2008

actually , this is a hot topic for me right now! so the surgery went well and most all was covered for me $ 150. co-pay was all. nothing was said about the fill co-pay in the Dr. office, just the office visit co-pay. Later I get a bill for $48 and they say that it is an "out patient surgery" for which my co would be $150, but they pro-rated it because the procedure would be LESS than that if I didn't have the insurance. that being the case I accepted that , reluctantly. SO..... that was the case the next 3 fills. NOW :angry they are billing me the $150 for the last!!! I've talked to them and the insurance people, both pass the buck and say it is the others fault and I must contact them. I finally got a simpathic insurance person who when to bat for me and finally said the hospital claims it is correct and I must pay it. I have a very long and costly trip to just get there, I just can't beleive the whole mess. I still owe the 150 , not sure when they will get it, but damm sure I won't have another fill if that is the way it will be!!! I am feeling restriction now, just keeping my fingers crossed. If anyone has any luck resolving this I would be gratefull to learn how.

forgve70x7 · January 8, 2008

Yeah I didn't have any problems with the surgery either, it's just the fills now. I have a friend who is a Dr and a lawyer so I am going to have him help me write a letter of appeal. There has got to be some definition of what a surgery is and you can't tell me that sticking a needle into a port constitutes a surgery. So far I've paid for the fill co-pays, but according to BCBS, anytime the skin is broken it's considered a surgery (except for vaccines). So far, I've gone in for 3 fills and one unfill. I'll keep you all posted on what happens with mine. I actually have to call BCBS again for copies of my EOB's because I accidentally threw them out.

ragdollx19 · January 8, 2008

I also have federal BCBS Basic and have to get my fills at a location that are not in network. Because most dr's will not give fills for other dr's patients i have to call BCBS and have them give me an out of network exception.

Anyway... I dont know if the above changes it at all, I would think not. I dont know what cpt code they use but mine also shows as a "surgery" and they pay all but a $40 co-pay. My daughter just recently had an outpatient surgery and my co-pay to the hospital was also $40.

My specialist co-pay is only $30. I am even irritated that I have to pay them the $40 because my insurance is paying them $560 and for me to go there as a cash patient I would only pay $150. They are robbing the insurance company and me as far as I am concerned. Charge me my $40 but for crying out loud dont make health care more expensive just because you can get the money from them. And people wonder why an employer would have an exclusion... because it will cost them so much!

I have had NO problems getting my fills paid for at all. Have you called BCBS yourself?

ragdollx19 · January 8, 2008

anytime the skin is broken it's considered a surgery (except for vaccines). So far, I've gone in for 3 fills and one unfill. I'll keep you all posted on what happens with mine. I actually have to call BCBS again for copies of my EOB's because I accidentally threw them out. :rofl:

You can print the EOB's off line. I do not like using the fepblue.org to print the eobs but the bcbs for your states website is much better looking and in pdf format. you can register with the state bcbs website as well as fepblue.org.

Thats such BS about the skin being broken. If you get a steroid shot or any other kind of shot its a surgery??

forgve70x7 · January 8, 2008

Apparently it's different for vaccines and stuff like that. I just called them today and apparently the code that is being submitted is a surgical code, but it's the only one my Dr's office has been told to use.

Ragdoll, I've been able to get them paid, it's just the co-pay that bothers me. $100 as opposed to the $30 I should be charged for specialty visits. Would you be able to get the code your Dr's office uses for their submissions? I wonder if it's different than the one I'm using.

Thanks,

Nichole

Pizzaman · January 9, 2008

Forgve, who does your fills, the doctor or a physician assistant? Because if it's the latter, I'd appeal under OPM regs. I don't think PA's can do "surgical procedures."

cheri52 · January 10, 2008

Forgve, who does your fills, the doctor or a physician assistant? Because if it's the latter, I'd appeal under OPM regs. I don't think PA's can do "surgical procedures."

what are "OPM regs"? mine are done by the assistant and I told the insurance person that and she said nothing about that. actually my insurance would benifit from this also because we both get slammed the way it goes down now!

forgve70x7 · January 12, 2008

Mine are actually done by the Dr's who did my surgery. They are the only ones in their office who do them. It gives them a chance to see how things are going as well. I do like how hands on they are, but this $100 per fill is driving me up a wall.

Pizzaman · January 12, 2008

what are "OPM regs"?

If you check the BC/BS OPM approved plan benefit book, the appeals procedures are laid out in section 8.

PTinUtah · January 16, 2008

those of you that have blue cross federal ins, standard option and used ppo doctors and hospital.... how much did you have to pay out of pocket total?

forgve70x7 · January 16, 2008

PT, I had the basic option so my out of pocket is probably different. it will also depend on your Dr and how much they and the hospital charges. I think my total out of pocket (for surgery and pre-surgical appointments) was around $1700. Most of that ($1000) was for 3 years of support through my Dr's office. One thing you want to ask at your Dr's office though is if they charge different amounts for insurance vs cash pay. I know they told me everything would be around $18,000, but the total submitted to insurance was over $40,000. When I asked about it, they said that they and the hospital give a discount to cash pay. So the total that they submit to insurance though is what your % out of pocket will be which means it may be substantially more. I hope that helps.

PTinUtah · January 18, 2008

I had not thought of that forgve. That doesnt seem right does it. I will ask Dr office about it. thanks for your reply.

ragdollx19 · January 19, 2008

I have the Basic option which is only slightly different. Total my surgery hospital and all cost me $150 (I guess some of the pain meds I got were considered RX)