# Blue Cross Dilema



## Peter Davidyock (Mar 20, 2011)

One of my general practices has been seeing a pt for some time treating a back problem.
The pt carried a policy with Carolina Care Plan until 12.31.10 at which time he switched to a Blue Cross Individual policy with a high deductible. 
Most every single new bcbs policy I have seen lately has an 18 month exclusion on it for pre-existing conditions. In essence that means that anything the pt has been treated for in the past is excluded for 18 months. Reasons for visits must be acute in nature until the exclusion period is over.
This pt consulted Hippa and discovered that if he could produce a letter of creditable coverage the exclusion period must be removed.
He did so and bcbs sent him a letter stating the they accept his letter of creditable coverage and that his exclusion policy is removed retroactively to the start date of his policy.
I resubbed all his open dos's regarding his back inj's and every single one of them denied again for exclusion.
I called bcbs and asked why. Their answer was unbelievable. I have never heard of it and it took me some time to get my mind around it.

Bcbs Rep: We have accepted the Pt's letter of creditable coverage and we are removing the exclusion period for pre-existing conditions retroactively to the start date of the policy for *NEW PRE-EXISTING CONDITIONS ONLY*. Since we already know about his back problems we will not honor the creditable coverage letter and we will deny any claim pertaining to the treatment of this persons back.

I have read and reread thier letter of acceptance to remove the clause and no where does it state that it is piecemeal. Quite the contrary it reads as all inclusive.

It is my opinion that Blue Cross is going down the toilet and I urge everyone to be vigilant when dealing with them.


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## Elizabeth Morgenroth (Mar 20, 2011)

Generally, the portability portion of HIPAA does not apply to direct enrolled policies.  So, while it is not advantageous to the patient, the Blue Plan is correct.  It applies to group to group coverage.  This helped patients who changed employers.


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## davisph (Mar 20, 2011)

*response*

I disagree, creditable coverage is creditable coverage whether they had medicaid, medicare ,etc... you should appeal it and if necessary file a complaint with the insurance commissioner, the only way that BCBS does anything is if they are threatened by complaints of a higher source as that goes against there record if they are not quick to resolve issues, also sometime the ones that you deal with at BCBS are not truly knowledgeable in what they are advising you so I would question them and appeal to a higher source that will get you resolve!!  You know that old saying..."the squeakiest wheel gets the most grease" that applies here!!


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## btadlock1 (Mar 20, 2011)

Oceanlivin said:


> One of my general practices has been seeing a pt for some time treating a back problem.
> The pt carried a policy with Carolina Care Plan until 12.31.10 at which time he switched to a Blue Cross Individual policy with a high deductible.
> Most every single new bcbs policy I have seen lately has an 18 month exclusion on it for pre-existing conditions. In essence that means that anything the pt has been treated for in the past is excluded for 18 months. Reasons for visits must be acute in nature until the exclusion period is over.
> This pt consulted Hippa and discovered that if he could produce a letter of creditable coverage the exclusion period must be removed.
> ...



There may be some mitigating factors that may make BCBS correct, but in absence of those, the rep that sent you the letter obviously doesn't comprehend the HIPAA portability provision: http://www.dol.gov/ebsa/faqs/faq_consumer_hipaa.html

"HIPAA is complemented by state laws that, while similar to HIPAA, may offer more generous protections. You may want to contact your state insurance commissioner's office to ask about the law where you live. A good place to start is the Web site of the National Association of Insurance Commissioners at www.naic.org. 

One of the most important protections under HIPAA is that it helps those with preexisting conditions get health coverage. In the past, some employers' group health plans limited, or even denied, coverage if a new employee had such a condition before enrolling in the plan. Under HIPAA, that is not allowed. If the plan generally provides coverage but denies benefits to you because you had a condition before your coverage began, then HIPAA applies. 

Under HIPAA, a  {Group} plan is allowed to look back only 6 months for a condition that was present before the start of coverage in a group health plan {Some individual plans have a 12 mo. lookback period, and up to 24 month pre-x exclusion period - FYI}. Specifically, the law says that a preexisting condition exclusion can be imposed on a condition *only if **medical advice, diagnosis, care, or treatment was recommended or received during the 6 months prior to your enrollment date in the plan*. As an example, you may have had arthritis for many years before you came to your current job. If you did not have medical advice, diagnosis, care, or treatment – recommended or received – in the 6 months before you enrolled in the plan, then the prior condition cannot be subject to a preexisting condition exclusion. If you did receive medical advice, diagnosis, care, or treatment within the past 6 months, then the plan may impose a preexisting condition exclusion for that condition (arthritis). In addition, HIPAA prohibits plans from applying a preexisting condition exclusion to pregnancy, genetic information, and certain children....

You may be able to shorten the pre-existing exclusion period, if you can show "creditable coverage." Most health coverage can be used as creditable coverage, including participation in a group health plan, COBRA continuation coverage, Medicare and Medicaid, as well as coverage through an individual health insurance policy. However, you should try to avoid a significant break in coverage (63 days) if you want to be able to count your previous coverage. If you have a break shorter than 63 days, coverage you had before that break is creditable coverage and can be used to offset a preexisting condition exclusion period. Days spent in a waiting period for coverage cannot be used as credit. But, they also are not counted toward the significant break (63 days) you are trying to avoid. "

I'm pretty familiar with the law, (I've used it a lot, and so I've actually read it...it's very redundant...), so these are the things I'd check if I were in your shoes...Individual policies aren't usually worth the paper they're printed on, and their protections are weak - But the federal law (eg, HIPAA) doesn't distinguish "newly-discovered" from previously-discovered", in regards to pre-existing conditions. *Conditions meeting the criteria for exemption *from pre-existing exclusions, *must be exempted - period.*

If you still have a copy of their previous CoCC, get it handy...You need to make sure that it reflects the effective date and term date, and something identifying the patient, individually. If it's not all there, call the payer and have them send you something better, that includes all of those things. 

Check to see:
A. If his term date on the CoCC is less than 63 days before his BCBS effective date. If it's 64 days or more, then the CoCC is virtually worthless, and BCBS is within their legal right to apply a pre-x exclusion. If it was less than 63 days (or no gap at all), see B.
B. Make sure he had continuous coverage for at least the amount of time that his pre-x exclusion w/BCBS would apply - BCBS should give you that info. If his waiting period is 18 months, and he had prior coverage for 18 months or more, then by law, his creditable coverage should completely offset his pre-x exclusion period. It's not a debatable subject - make that clear to BCBS in your appeal. If they refuse to rescind the pre-x exclusion in this situation, advise them that you will file a complaint with the US Department of Labor, the OIG and your state department of insurance, and cite the laws they're breaking. If they don't comply, then follow through on those threats. You are in the right.
C. If they didn't have a significant break in coverage, but had less time in continuous coverage than the pre-x period, BCBS should still credit the prior coverage to knock off some of the waiting period (equivalent to the amount of continuous coverage they had). If they had more than one prior policy (again, without any significant breaks), submit those CoCC's as well, and they will count, too.

Also remember that *pre-x only applies to conditions addressed during the pre-determined look-back period*, which is probably 12 months for this individual policy. Assuming his credible coverage won't work, BCBS can ONLY deny something as pre-existing if his records indicate that he sought medical advice or treatment for it during the lookback period. For example: John Smith has chronic back pain. He's had insurance off and on, but prior ro his current policy, he went 4 months w/o coverage. His new plan has a 12 month pre-x waiting period, and a 6 month lookback period (since he's enrolled through his employer). His effective date is 1/1/11. John's insurance (BCBS for example's sake), is allowed to request all physician, hospital, clinical, and pharmaceutical records on him from 7/1/10 - 12/31/10 for a pre-existing investigation. If in those records, there is any mention of the patient complaining of back pain, getting advice on dealing with back pain, relevant treatment or prescriptions for back pain (including refills on medication regimens that were begun prior to the lookback period), they can deem his back pain pre-existing. If he never saw a doctor or filled a prescription during that time frame, then he has no pre-existing conditions, according to the federal law's definition. I've seen some insurers whose investigation process is _brutal_ - BCBS in general, isn't normally all that bad - they usually only investigate one condition at a time, as they get claims for them. You can usually avoid triggering a pre-x investigation on BCBS patients by making sure that the onset dates (Boxes 14 & 15 on the CMS1500 form) are completed, and that they reflect that 'this visit is the first time the patient has been treated for or experienced the symptoms' that prompted the visit. 

I hope that was useful, and not too much info! Please let me know if you have any other questions...


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