Blue Cross Blue Shield NC Purges Their Provider Rosters Without Informing ANYONE

I had not had a BCBSNC client in several years when I picked up one a few months ago.  I have a BCBSNC Provider Number given to me by that insurer after filling out a truckload of paperwork 5+ years ago.  I gave my biller the insured person's information and what got spit back out was that I was an 'out of network provider' (death curse).

So, I called them up.  The  client called them up.  The some employee advised me that I had to fill out the reams of paperwork again.  I started crying.  Did she understand how much paperwork she was talking about? Why didn't the company utilize CAQH....an online data base WHOSE SOLE PURPOSE is to keep tabs on providers so that insurance companies can access information like current malpractice insurance/ current licensing information (DUH: you can go to the NC Psychology Board to see if I am 'active' or not). 

As is usual with United HealthCare/ Humana---both Medicare Advantage companies so unregulated that CMS (Centers for Medicare and Medicaid Services) HUNG UP on me when I asked if I could obtain a copy of the new contract these 2 'Advantage' companies had signed with CMS in July, 2014----BCBSNC----which is the 'State Plan' for NC (teachers; state employees)----is very difficult to interface with. 

So, after the crying episode and a period of recovery I resolved to start at the top end of things...that being the NC State Legislature which oversees BCBSNC in terms of the 'State Plan'----figuring it would lead me to info about the company in general.  It did. 

I called the general number for the NC State Legislature.  That lead me to the 'librarian' for them.  That lead me to a manager of the 'State Plan', Thomas Friedman at 919 420 1355.  He indicated that the 'State Plan' had bee assigned 2-3 years ago the Department of the Treasury for the state of NC as things went amuck (gee: wasn't that when the Republicans took over the State Legislature).  Actually, it seemed like a good idea that the 'State Plan' was not being managed in a partisan fashion and the feeling I have gotten from talking to people is that BCBSNC is so powerful that they sit in committee meetings and give the thumbs up or down to things being discussed by the state legislature. 

In any case, Mr. Friedman gave me the telephone number for the overall liason who is the go-between BCBSNC and the state legislature/ Treasure Department.  She is an employee of BCBSNC.  Her number is: Ms. Evans: 919 608 3148. 

This is what I told her: "Hi Ms. Evans. thanks for yr assistance.  As I mentioned I am Marsha V. Hammond PhD, Licensed Psychologist NC # 2748.  NPI is 1194700591.  I am assigned a BCBSNC provider # which was given to me years ago. I can get that if you need it.  As I stated, in February, 2014 I was apparently purged from the BCBSNC provider panel for no apparent reason.  I have a BCBSNC client who works at the canton NC papermill with depression whom I have seen several times over the past several months.  My biller submitted billing which went nowhere and after several very unhelpful conversations with BCBSNC employees they informed me that 'we thought you were out of practice' for no good reason.  My address has not changed.  My license and its status has always been viewable at the NC Psychology Board site.  My CAQH  credentialing information is current.  CAQH is an online management tool that insurance companies use.  BCBSNC is listed there as having access to all my professional information.  I do not believe it is fair or just to require me to go thru months of waiting and dozens of pages of paperwork when I already did that years ago and I have a BCBSNC client requesting outpatient mental health services.  They did NOT inform me of anything for I have reviewed my e mails back to the beginning of 2014.  Besides this there is NO insurance company with whom I am familiar with that purges providers from its roster FOR ANY REASON unless the provider sends to them in writing a request to do so. Thus BCBSNC has violated an industry wide standard and I can only assume the purpose is to create a barrier to care by a well qualified practitioner.  thanks for your help.  Marsha V. Hammond, PhD"

Yeah: we will see where this goes.  I think it will go like this: when the insured calls her number and states something like "M.......f.......... I need for my mental health services to be paid for"...upon which she will say, "What did you say?" (please see previous post for relevance)....and then she will say, "You understood me right, M.......f.........  I want my outpatient mental health services to be paid for..."

Egads: these people just don't seem to respond to anything but point blank rudeness.  Who has all day to dance around their faux nice statements?

This is how you get United HealthCare to pay for outpatient Mental Health Services

Can't get United HealthCare, a Medicare 'Advantage' company----completely unregulated at any level in the US----to pay you for outpatient mental health services?  This is how you settle the matter.

1. You file appeal after appeal indicating that that since they lured clients away from Medicare using some guy at Eblen Charities at the back of Earth Fare Grocery store in Asheville, NC who indicated to your client: "We will pay for all mental health services."  So, go get your picket-gear on and hold up your sign which says: "United HealthCare = No Mental Health Care Services.

2. Your client calls up United HealthCare and has the following conversation after numerous attempts at trying to get his outpatient psychiatric and mental health care paid for: "Listen M.......f........"; "What did you say?"; "You heard me right M.......f.........   I am right now in the process of going back to Medicare.  I expect you to pay for my mental health services." 

You can't believe how fast this provider got a letter in the mail indicating that she would be paid back to the beginning of the year. This being said, I don't got no check in my mail box and so I sent yet another appeal to United HealthCare and Maximus Federal who is supposed to monitor them---indicating I had no check tho I had received a letter indicating I would be paid. 

I'll believe it when the check is in my hand.  I advised the very excellent psychiatrist to re-file his billing with United HealthCare. 

Meantime, the client has returned back to Medicare for what they will do once....they will do again.

United HealthCare Refuses to Pay for Outpatient Mental Health Services

After numerous appeals to United HealthCare (an oxymoronic company described as a "medicare advantage company' by medicare (CMS: Centers for Medicare and Medicaid Services and supported by American Tax Payers----A PRIVATE COMPANY), I am told that outpatient mental health services will not be paid for associated with a client of mine who was LIED TO by this worthless company when he changed from Medicare to United healthcare....all the while being assured that he would be benefited mental health outpatient mental health services----which he had advised them was a 'deal breaker.' 

They don't care. They simply lie. 

Now the client has a huge bill from his psychiatrist.  And I am told that as associated with a 'Waiver of Liability Statement' which I was demanded to sign in order to submit my appeal, that I may not submit my bill to the client whom I advised prior to signing up for any worthless Medicare Advantage company rather than Medicare. 

Maximus Federal, who CLAIMS to "WE WORK FOR MEDICARE" (their bold on the side bar of a letter to me), indicates that as I was 7 days past the 60 day limit to file an appeal...after billing and billing and appealing----that they side with United healthcare---who is supported by American tax payers.  This private company----just like Humana---another Medicare Advantage plan company---has an administrative oversite fee of 18% of better whileas efficient medicare has an administrative oversite fee of <5 p="">
We are a nation of duped people.  We support private companies who ream us with our own tax dollars---all the time believing what they say---which is that they will pay for outpatient mental health care. 

They DON'T; they WON'T; they are COMPLETELY UNREGULATED ACCORDING TO THE NC INSURANCE COMMISSIONER'S OFFICE E.G.,SHIIP.

So why the hell do we put up with them?  I swear...the next time I see that United healthcare van driving around Asheville, NC, I might be inclined to put on my non-reflective Ninja suit and pull out my black spray paint and make a point.  

Lying Medicare Advantage Plans (and CMS, Center for Medicare & Medicaid Services) Which Covers for Them

Twice yesterday I called CMS (Centers for Medicare & Medicaid Services) to ask about the July 2014 contract signed between Medicare Advantage Plans that my clients have with Humana and UnitedHealth Care. 

                                                    Twice I was hung up on. 

I was simply pressing to speak to someone ANYONE at CMS who could give me details about outpatient mental health care changes that have already gone into effect though they are not supposed to until 1.1.2015.  I was told to do this by the NC Insurance Commissioner's Office, the SHIIP Division which oversees Medicare and has no power in any way over Medicare Advantage Plans. 

Prior to calling CMS I called Palmetto GBA, a company which oversees Medicare in NC.  There was no one to speak to AT ALL regardless of what triage tree I tried e.g., "try 1....press 4.....go back to beginning", etc.

In 2008, the NC State Legislature passed a bill which demanded mental health parity.  That is to say, that mental health services were to be covered in a similar manner to physical health services.

Great! But as NC SHIIP personnel at the NC Insurance Commissioner's Office informed me this week, that did not pertain to policies associated with Medicare-eligible consumers.  That would be: disabled people or anyone 65 or older.  THE MEDICARE ADVANTAGE PLANS WERE EXEMPTED.

In July, 2014, Humana; UnitedHealth Care and assumeably, other Medicare Advantage Plans signed a NEW CONTRACT with CMS. This is not well known, to say the least.  I knew that something was up as my remissions came back (for Humana) with half the reimbursement I had received the first half of the year.  (AND AS PER BELOW, THIS IS NOT SUPPOSED TO START UNTIL 1.1.2015 according to the 2015 Medicare Manual, just released to Medicare insured).

And I knew something was terribly wrong with UnitedHealth Care as I have appealed numerous times (if you go over 60 days to appeal they use this as an excuse to gig you) and had been paid nothing to see a client of mine with SPMI (Severe Persistent Mental Illness) who switched from Medicare to UnitedHealth Care 1.1.2014.

 I learned about this'new contract' in a round-a-bout way as associated with talking with Humana/ UnitedHealth Care/ CMS/ NC Insurance Commissioner's Office (SHIIP, specifically, which 'oversees' these plans; according to head of SHIIP in NC, there is NO over-seeing of these plans at all in NC as they are federally mandated/ created plans; she took 2 days to return my calls and then I had to call her).

SHIIP representative John Ciccone in Waynesville, NC has indicated to me that he advises all who come to him the following re: the Medicare Advantage Plans: 1. they have nothing to do with Medicare 2. they are completely unregulated 3. they write their own rules.

I have always advised my clients to stick to Medicare and avoid the Siren-like lures of the Medicare-Advantage Plans----an oxymoron if there ever was one. They are enticed with the promise of cheaper medications, mostly. And these are impoverished people who cannot afford an additional payment related to an extension of Medicare Part D which administers medications.  Psychotropic meds can be very expensive.

In any case, this is my experience these past two weeks re: CMS/ Humana/ UnitedHealth Care as associated with diminished reimbusement (HALF OF MY PAYMENT PRIOR TO JULY, 2014); non-payment after numerous appeals and complaints----and being hung up on twice today by CMS as I asked to have information re: the new contract signed between CMS and these two companies

I will get to NCBCBS in a subsequent post.  They don't even pay though I am a designated provider on their panel since 2008. They tell their insured all kinds of inane stories about how this entity didn't talk to this one; errors codes on my remittance say I am out of network (when I am assigned a number) and any other bullshit you can think of to cause you to pull your run down the street with your hair on fire....

So, let's take a look at the Medicare & You: Official U.S. government Medicare handbook (2015).

Section 5 (page 75): Learn about medicare Advantage Plans (Part C) & Other Medicare Health Plans: 

"In all types of Medicare Advantage Plans, you're always covered for emergency and urgent care." 

                This is a lie as evidenced by the following recent article in the New York Times

 http://www.nytimes.com/2014/09/29/us/costs-can-go-up-fast-when-er-is-in-network-but-the-doctors-are-not.html?_r=0

Costs Can Go Up Fast When E.R. Is in Network but the Doctors Are Not

"....When legislators in Texas demanded some data from insurers last year, they learned that up to half of the hospitals that participated with UnitedHealthcare, Humana and Blue Cross-Blue Shield — Texas’s three biggest insurers — had no in-network emergency room doctors. Out-of-network payments to emergency room physicians accounted for 40 to 70 percent of the money spent on emergency care at in-network hospitals, researchers with the Center for Public Policy Priorities in Austin found.

“It’s very common and there’s little consumers can do to prevent it and protect themselves — it’s a roll of the dice,” said Stacey Pogue, a senior policy analyst with the nonpartisan center and an author of the study...."

SO, relatedly, I have been a Medicare provider for over 10 years.  This allowed me and my clients seamless delivery of services----for after all----they were Medicare Advantage companies----being supported by American tax payer $$---to the tune of 18% overhead administrative costs versus Medicare's 5% or less overhead administrative costs----RIGHT? And prior to July, 2014, the reimbursement was the same---more or less---for outpatient mental health services.

       Correct: until the new contract was signed in July, 2014 which is not to go into effect until 1.1.2015.  

After July, 2014, my remittances revealed as associated with Humana that they were paying me half of what Medicare would pay me for outpatient mental health services....half of what they had paid me prior to July, 2014.

When I called Humana, the woman on the phone did a very fast verbal tap dance around what I was paid until I basically said she was lying. These calls are recorded "for the purposes of training" and so she couldn't hang up.  This apparently was not so regarding the CMS phone calls outlined above.

When I challenged UnitedHealth Care as to why THEY WERE NOT PAYING ME AT ALL after 1.1.2014 for a previously Medicare insured client, they simply ignored me.  Then, mysteriously, after appeals to Maximus Federal which is sometimes mentioned in the small print on the remittances I receive outlining what I am paid and what the client is responsible for---but which was described by SHIIP personnel as a 'ghost entity' which simply feeds back to the companies themselves but which is supposed to be part of CMS----I started being paid by UnitedHealth Care albeit at a lesser rate with a descriptor associated with the money that it was 'tied' to Medicare.

Both of these companies have their mental health care/ behavioral health care outsourced to other companies.  So, you can call them or their ancillary companies and never get an answer----which assumeably is what they count on...that you give up. I call them while I am driving for otherwise I would not be able to work.

To suit, and as related to BUYER BEWARE, the following is in the 2015 Medicare Manual:

"If you're in a Medicare Advantage Plan, review the "evidence of Coverage (EOC) and "Annual Notice of Change" (ANOC) your plan sends you each year...The ANOC includes any changes in coverage, costs, provider networks, service area, and ore that will be effective in January." (NOT JULY). 

Broadly, as associated with 'changes' in Medicare Advantage Plans in NC for 2015, I found this website:

 https://www.careimprovementplus.com/prospectmember/northcarolina-medicare-health-plan-benefits.aspx

2015 Annual Notice of Changes

The documents below are the Annual Notices of Changes for each plan. The information in these documents tells you about the differences between the 2014 and 2015 plan. Please note this is only a summary of changes. It is important to read the Evidence of Coverage to understand how the plan works. For any questions or concerns, please call Customer Service.

• Care Improvement Plus Medicare Advantage (PPO)

DOCUMENT COMING SOON

                                                          Gee, that's helpful.

So, in googling "Humana 2014 Annual Notice of Change" here is what I found:

Humana website: https://www.mymedicareanswers.com/community/news/blog/2014/08/29/question-and-answer-fall-open-enrollment-and-annual-notices-of-change

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- See more at: https://www.mymedicareanswers.com/community/news/blog/2014/08/29/question-and-answer-fall-open-enrollment-and-annual-notices-of-change#sthash.VWhaFslx.dpuf

"...Medicare plans may change their coverage rules and costs each year. Every fall, you should receive information from Medicare or the private insurance company administering your Medicare benefits explaining how your Medicare health and/or drug coverage WILL CHANGE FOR THE UPCOMING YEAR. -

And, in googling "UnitedHealth Care 2014 Annual Notice of Change" here is what I found: quite simply put a  compendium of dog-chasing-his-tail information.

Post Script to this fine woman mentioned in the NYT article: Public Policy Priorities in Austin, Stacey Pogue: SISTER, TAKE A LOOK AT THIS. (pogue@cppp.org)