BCBS Screwing Me Over

D

DemandFairness

New Member
3
BCBS are a bunch of incompetent crooks! I've had nothing but displeasure while dealing with this abominable company. My grandpa is really the only person in my life that has a stable financial situation, so he helps me out in every way he can. Last year, he started paying for my BCBS insurance plan at $400/month. I had a $2,000 out-of-pocket max with combined prescription and medical (prescription AND medical money both go toward the out-of-pocket max). The plan started in January. Come August, and I think something is fishy because I feel I should have reached my out-of-pocket max by now. I call Prime Therapeutics (my prescription coverage) and they tell me that my reached out of pocket max is a completely different number than BCBS tells me (my medical coverage)!!!! They forgot to combine my medical and prescription out-of-pocket numbers!!! So, I speak to a manager, and he apologizes that this happened, and they take weeks to fix it! In the meantime, I should have already reached my out-of-pocket max months ago! The manager tells me they owe me $1,300 and they would send me my money immediately. That was about 10 months ago. I've been calling them almost every 2 weeks since this has happened, and every time I call the person that picks up the phone can't seem to find the "reference number" that this incident refers too. It takes about one hour of explaining and being passed around from department to department to finally get a manager that can find the referenced situation. I even got a manager once that personally promised to take care of it within a week and gave me his direct number. 2 months passed, and I receive no checks, so I call his number - of course he doesn't answer, I leave a voicemail, and never get a call back.....

I would sue this company if it were more money (the attorney fees and time aren't worth it), but the way this company runs it's business is abysmal. Oh, and remember how I said last year it ran me $400/month? Well this year it decided to hike it up to $500 and cover less medications for me. Yippee!!! I feel completely at the mercy of insurance because what are we to do? I want some way to be able to fight back, but I'm just not sure how to...

One more story. I had multiple tests done at Cleveland Clinic in Ohio, and I get a huge bill from them many months later. I call BCBS to see why they hadn't paid, and they claimed I didn't pay my insurance fee for that month so I didn't get coverage. I went back into my records, and found an exact date and time that I paid my fee, and told the lady on the phone. She apologized, and said that she would reprocess the claims with Cleveland Clinic. Is this a joke??? AM I DREAMING??? The claims still haven't been processed and I STILL owe money to Cleveland Clinic that I should not owe.

How do I battle against this evil company or any insurance company in general that treat its clients like complete crap?
 
Assuming you are in Florida (unsure because of the tests run in Ohio) while no one can help you with prior claims (Florida Blue isn't that bad with claims, it sounds like you have gotten the run around because you have spoken with bad CSRs) the first thing you should do (if you haven't already) is register your account online at https://www.floridablue.com/#.

This allows you to track every claim and see exactly where you are relative to out of pocket expenses in almost real time-it's much easier to deal with payment and claims issues when it's early in the process.

You also need to learn how to read an EOB (Explanation of Benefits)-these are mailed when each claim is filed and gives you detailed information regarding your deductible as well as your annual limits (such as the Maximum Out of Pocket).

Drug formularies change each year so you need to review them before the start of the year during Open Enrollment and make sure the insurance company covers them. If they don't many of the more expensive medications might be covered under what is called Patient Assistance Programs and you could get them for free, particularly if your income is limited.

I also wonder why you are paying so much for health insurance, it would seem that you would qualify for a premium subsidy with lower premiums and out of pocket costs if a family member is paying the premium.

All of these issues would be easier for you to handle if you went through an agent, who costs you nothing and provides valuable advice. I'm not interested in doing this but there are others on this forum who might-if you have Florida Blue then you need an experienced Florida Blue captive agent.
 
Also, while it appears that its ONE system to the consumer, its 2 separate systems. And while eligibility feeds from BCBSFL to Prime 3 days a week, the oop dollars probably go from Prime to FL monthly, if then.

1. You need an agent
2. Why are you paying $400/month? It sounds like you are subsidy eligible
3. Call BCBSFL Tuesday am at 758am. (Not kidding. You want to be first in the queue.)
4. Tell whoever answers what is going on. (Keep in mind, its not their fault), but they need something to tell the supervisor.
5. Its going to take a while. When they say "I'll get back with you", do NOT hang up. Tell the supervisor how much money you are owed and that you want a check in 10 working days. Make sure you get the reference # to the call.
6. If they say anything besides "yes, sir", tell them you are going to the DOI with an official complaint, due to the companies incompetence.

Just as an FYI, I have more than 50 clients on BCBSTX with a $6K deductible AND out of pocket max. These clients typically hit the $6K by March 1 All of them knew prior to purchasing the policy, that when they had met the $6K in expenses, they were going to have to call me, so I could send an email to make sure the medical and RX (Prime) system dollars had merged. And assume a week for the merge.

No one is laying in bed at night trying to figure out how to _______ over clients. But the issue you are talking about happens to less than 1% of enrollees. In an industry whoss systems are antiquated, at best.
 
Last edited:
While this is an awful situation, I do hope there is a lesson learned. There is incredible value with working with an independent agent which can be done at no cost to the consumer. Much of this work would have been done by the agent on the behalf of the consumer. Of course if this is in a state where the agents have been cut out, then hopefully the consumer takes up the fight to get the agents back in the mix.
 
Krball said:
While this is an awful situation, I do hope there is a lesson learned. There is incredible value with working with an independent agent which can be done at no cost to the consumer. Much of this work would have been done by the agent on the behalf of the consumer. Of course if this is in a state where the agents have been cut out, then hopefully the consumer takes up the fight to get the agents back in the mix.
Click to expand...


The problem is the there isn't enough comp to warrant any extra service work.
 
DemandFairness said:
BCBS are a bunch of incompetent crooks! I've had nothing but displeasure while dealing with this abominable company. My grandpa is really the only person in my life that has a stable financial situation, so he helps me out in every way he can. Last year, he started paying for my BCBS insurance plan at $400/month. I had a $2,000 out-of-pocket max with combined prescription and medical (prescription AND medical money both go toward the out-of-pocket max). The plan started in January. Come August, and I think something is fishy because I feel I should have reached my out-of-pocket max by now. I call Prime Therapeutics (my prescription coverage) and they tell me that my reached out of pocket max is a completely different number than BCBS tells me (my medical coverage)!!!! They forgot to combine my medical and prescription out-of-pocket numbers!!! So, I speak to a manager, and he apologizes that this happened, and they take weeks to fix it! In the meantime, I should have already reached my out-of-pocket max months ago! The manager tells me they owe me $1,300 and they would send me my money immediately. That was about 10 months ago. I've been calling them almost every 2 weeks since this has happened, and every time I call the person that picks up the phone can't seem to find the "reference number" that this incident refers too. It takes about one hour of explaining and being passed around from department to department to finally get a manager that can find the referenced situation. I even got a manager once that personally promised to take care of it within a week and gave me his direct number. 2 months passed, and I receive no checks, so I call his number - of course he doesn't answer, I leave a voicemail, and never get a call back.....

I would sue this company if it were more money (the attorney fees and time aren't worth it), but the way this company runs it's business is abysmal. Oh, and remember how I said last year it ran me $400/month? Well this year it decided to hike it up to $500 and cover less medications for me. Yippee!!! I feel completely at the mercy of insurance because what are we to do? I want some way to be able to fight back, but I'm just not sure how to...

One more story. I had multiple tests done at Cleveland Clinic in Ohio, and I get a huge bill from them many months later. I call BCBS to see why they hadn't paid, and they claimed I didn't pay my insurance fee for that month so I didn't get coverage. I went back into my records, and found an exact date and time that I paid my fee, and told the lady on the phone. She apologized, and said that she would reprocess the claims with Cleveland Clinic. Is this a joke??? AM I DREAMING??? The claims still haven't been processed and I STILL owe money to Cleveland Clinic that I should not owe.

How do I battle against this evil company or any insurance company in general that treat its clients like complete crap?
Click to expand...


Could you please post information that would identify the plan, such as the name and number? Also, what state would be helpful too.
 
I'm in Florida and I have the BlueOptions 1424 All Copay plan. Does that help? By the way, where can I find an insurance agent - can I get one for free or is it too late?
 
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