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BC/BS 38000 in Texas

Jeffrey Sirianni audioman at hctc.net
Thu Jun 18 11:57:06 EST 1998

An update:

I spoke with our regional field representative for BC/BS.  He said that the
revised benefits that I described below are for the disputed case only,
which is a HUGE relief, and that the $500 per ear every three year benefit
would remain in place, for the time being.  My office manager was under the
impression that it was going to be a change for all participants in the
BC/BS 38000 members.  She played "devil's advocate" and took the position
of "Is this fair to all the BC/BS 38000 members if BC/BS revises the
benefits allowed in a disputed case as I've described below", which I kind
of see her point.  In any event, I told the field representative that I
would be delighted if asked to sit in as a consult when and if benefit
guidelines are changed.  I recommend all Texas providers of this plan to do
the same.


At 11:37 PM 6/16/98, Jeffrey Sirianni wrote:
>To Texas Providers of Hearing Aids via BC/BS 38000:
>A recent problem arose in our office that has opened a very large can of
>worms.  As those of you know, the plan provides a benefit of $500 per ear
>every three years (it could be five years, I'm not sure).  An informal
>survey of providers I know say that they do the following for binaural
>1. Select with the patient, the devices desired.
>2. Explain to the patient that BC/BS 38000 will cover the first $1000 and
>that the patient is responsible for charges over $1000.  For example, if a
>binaural fitting runs $2400, BC/BS 38000 will pay $1000 and the patient is
>to pay the balance of $1400.
>3. Fit and dispense the devices and collect $1400 from the patient.
>4. At the end of the trial period (and the devices are kept), bill BC/BS
>38000 for $1000.
>Well a patient of mine, who has failed to pay her outstanding balance, has
>made a big stink with our office and with BC/BS 38000.  Using the example
>above, she agreed to pay $1400, but in two payments of $700, $700 on
>delivery and $700 at the end of the trial period, which we agreed as she is
>an established patient.  Hearing aids were dispensed, patient paid $700,
>and we billed and collected $1000 from BC/BS 38000.
>The patient has not made her second payment of $700 and this was due 6
>months ago.  She was about to be sent to a collection agency when she
>called our office to tell us that she looked into the BC/BS 38000 plan and
>now interpreted the BC/BS benefits to cover hearing aids (the $1000
>benefit) to be payment in full.  In other words, she says the $1000 benefit
>is the "allowable" by BC/BS 38000 and that we cannot bill her for anything
>above $1000.
>Our office manager has been on the phone with the BC/BS field
>representative and he has had six people in their legal department look
>into this matter.  Well bad news hit today.  The field representative has
>said that BC/BS will be establishing new guidelines for billing the 38000
>plan, including a 10% markup over invoice cost, plus ancillary billing
>codes (ie fitting and dispensing fees).  I'm not sure what the allowable
>wil be, but it is a pretty lousy plan, at 10% over invoice.  It sounds to
>me like they don't want us to make any money from these patients AND that
>they do not put a fair dollar amount on our profesional skills and
>services.  I am outraged that they are implementing such a program without
>the consultation of audiologists.
>Comments please from BC/BS 38000 providers....

* Jeff Sirianni, M.A., CCC-A                      *
* Sound Advice / R.G. Delaney, M.D.               *
* 710 Water Street / Suite 404                    *
* Kerrville, TX  78028                            *
*                                                 *
* (830) 896-1433                                  *
* (830) 896-1440 FAX                              *
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* audioman at hctc.net                               *
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* Discussion Leader of bionet.audiology Newsgroup *

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