Crossing border for health care not as simple as it seemed on BlueChoice network

jholleman@thestate.comApril 16, 2014 

S.C. resident Daniel Martin picked a BlueChoice HealthPlan insurance policy through the new Health Insurance Marketplace in part because his North Carolina primary-care physician was on the provider list.

Martin and his physician’s office even made calls to BlueChoice to confirm it, and his first visit to the doctor was covered.

Then, last week, Martin was diagnosed with a ruptured disc in his lower neck and scheduled for immediate surgery, only to find the S.C.-N.C. state line was a huge hurdle.

In the end, BlueChoice is going to cover his surgery, and its parent company, BlueCross BlueShield of South Carolina, is admitting its online list of providers was confusing, even to its own customer-service agents. The website will be updated, but S.C. customers like Martin who signed up because they thought they could use North Carolina doctors still will face hurdles.

The Columbia-based insurer plans to reach out to BlueChoice members who have encountered similar situations to clarify its provider network and out-of-state policy, said BlueCross BlueShield of S.C. spokeswoman Patti Embry-Tautenhan.

Martin appreciates BlueCross BlueShield has understood his argument. But he is frustrated at the delay in his surgery, which had been scheduled for Monday, was rescheduled for Tuesday when his coverage first was denied and now is scheduled for next Monday.

“This is probably an overstatement, but I could be paralyzed by next Monday,” said Martin, 63, of Lake Wylie. “The neurosurgeon had told me we needed to get this done as quickly as possible. I went in on Friday, and he cleared his schedule to do it on Monday.”

This isn’t the typical tug-of-war with an insurance company to cover a certain procedure. Private insurance companies had to create new products and set up new purchasing procedures for the Health Insurance Marketplace under the Affordable Care Act. It was inevitable there would be bumps in the road.

The Martin case made it clear that BlueChoice’s online list of provider networks was unclear, even to some of the company’s employees.

“For health insurance to work effectively, there are procedures that must be followed,” Embry-Tautenhan said. “We recognize that especially for people new to health insurance, those rules can sometimes be confusing.”

BlueChoice HealthPlan provides access to care outside of South Carolina through its network, but that is supposed to be only for urgent care. In unique circumstances, BlueChoice members can get specialty care outside the state with prior authorization, Embry-Tautenhan said. Part of the confusion arises because the out-of-state rules are less strict for other BlueCross BlueShield policies that also are on the insurer’s network.

“That information was not clearly communicated on the BlueChoice website, and we are taking corrective action to clarify it,” Embry-Tautenhan said. “We apologize to any member who has been inconvenienced.”

Martin said his primary-care physician, Dr. Marshall McMillan, and Presbyterian Medical Center in Charlotte both were included in the original online provider list. Martin even checked again after purchasing the policy by typing in his policy number.

BlueChoice paid for Martin’s first visit to McMillan. Martin started running into problems when he was referred to Carolina Neurosurgery, even though that office also thought it was in his network.

Martin still is concerned that he apparently will have to get prior authorization for any care in North Carolina. “Taking away the part of the network that enticed me to pick this plan would amount to a bait-and-switch scheme,” he said.

The fact the company’s own customer-service personnel gave out the wrong information to Martin is an indication of how confusing the details were on the website. Embry-Tautenhan acknowledged that, in Martin’s case, the “customer service effort didn’t work as well as it should have.”

 

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