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In-Network Claims Sometimes Paid at Out-Of-Network Rates


Source: Nicole Helfrich, Titan Health

Blue Cross Blue Shield (BCBS), one of the largest health insurance networks in the country, has 36 independent BCBS companies insuring more than 107 million members across all 50 states, the District of Columbia, and Puerto Rico.


To facilitate proper claim processing, BCBS assigns a three-letter alpha prefix to each policy to identify the state or region where the policy originates. This prefix enables local BCBS plans to redirect claims to the correct “home” plan so they can be adjudicated at the contracted in-network reimbursement rate and plan benefit level.


For the most part, the BCBS system works well. However, Titan auditors occasionally find that BCBS plans incorrectly process out-of-area claims as out-of-network, reimbursing the provider at the lower out-of-network rate and assigning a much higher deductible and/or co-payment responsibility to the patient. Obviously, both patient and provider are very unhappy when this happens.


To help catch this payment error when it occurs, Titan recommends that hospital staff note the patient’s expected in-network co-payment and deductible amounts on their account when verifying eligibility. Claims can then be flagged for review if the patient responsibility exceeds that amount.

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