Blue Shield of California is processing many claims as “Hosp Misc” rather than as the CPT code submitted by the provider. Anyone else seeing this?
I had to drop from Blue Shield of CA Platinum PPO this year down to Gold due to rising costs. (Purchased individually through Covered CA.)
I’ve noticed in MANY instances that UCLA is sending bills to BSCA with specific CPT codes and they are being processed by BSCA as “Hosp. Misc.,” which means that instead of being charged a co-pay, as I would be if they were processing the code as received from UCLA, I am instead being charged 30% co-insurance. This is double or triple what the co-pay would be.
I appealed some of these claims and BSCA just denies the appeals saying they were processed correctly. How can they be processed correctly if the CPT codes submitted by the provider aren’t what BSCA is showing on the EOB?
Is anyone else noticing this? Any advice? Is my next step to file grievances for all of these service dates with CA DMHC?
This is exhausting. I’ll be paying BSCA about $40,000 out of pocket this year. 🫠 You’d think with all of the money they bring in they could at least provide the basic services they are contracted to provide… the most basic of which would seem to be processing claims correctly. But I know that’s unfortunately not how they work….
Anyone else experiencing this? What do I do next?
Edit: I love that I can get more helpful answers on Reddit immediately than I’ve been able to get after HOURS on the phone with multiple billing departments at UCLA and multiple departments at BSCA. Everyone I spoke to at all of these departments had no idea what was happening. I mean, isn’t this what they do all day long? Again, navigating these systems is so exhausting. Thanks to those who commented. I’ve always gotten “facility fees” at UCLA, but I think when I was on the platinum plan I wasn’t as shocked by them as they were a 10% copay vs a 30% copay on the Gold plan. (Another confusing thing - why call the plan “Gold PPO 80” when it’s actually only paying 70%? 🤔)