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BCBS Refund Requests

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Blue cross blue shield has experienced several issues these last few months that have resulted in claims being processed incorrectly. Starting October 1st 2019 - all FL BLUE plans (have an H in the member ID) - should have been DENIED if billed to BCBS and resent to ASH for processing.

In some instances, BCBS paid these services instead of denying them - which is partially causing the refund requests they are sending. The majority of the refund requests are coming as a result of an internal audit being performed by BCBS on ALL PROVIDERS. On 1/9/2020 because in addition with the FL BLUE/ASH switch over, they were wrongfully processing provider's claims as out of network with the provider has ONLY ever been in network.

We have been working diligently to dispute/appeal these instances in which BCBS applied a patient's benefit to an out of network deductible, causing them to owe when they shouldn't - and spoke with claims staff when we noticed they were paying at a different fee schedule than usual.

BCBS is going back through claims and making sure they all processed correctly, and are in the processes of retroacting those claims which were processed and paid at the out of network fee schedule, which represents a higher allowed amount than the BCBS fee schedule, ergo the refund requests piling up. Once funds are re-paid to BCBS, the proper amount will be released when the claim completes it's 're-processing' phase.