FEP Blue Cross Overseas GeoBlue - Problem with Guarantee of Benefits

[jas007]

Here’s the situation in a nutshell:

 

I had surgery as an inpatient and was admitted to a preferred provider for one night. The hospital had previously submitted an “estimate of charges” for pre-approval and in response,

GeoBlue approved the amount for the surgery and related costs based on the hospital’s estimates.  The hospital would receive everything they asked for.
 

Anyway, all went well with the surgery, but when it was time to leave, the hospital billing office called my room and explained that since the actual charges exceeded the maximum amount set out in the guarantee of benefits letter, I would need to pay the difference of 21,000 baht or so.  No big deal, but I was under the impression that the terms of the agreement between the hospital (preferred provider) and Blue Cross provided that the patient’s bill would be paid in full for all covered expenses, and that claims for any amount due would be settled between the hospital and the insurer.

 

Anyway, rather than argue too much with the billing office, I just paid the bill.  I was told that when the final charges are finally settled and paid, that I would be reimbursed.  
 

Am I wrong in thinking that this is a matter usually settled between the hospital and the insurance company, and that the patient should not be presented with a bill at discharge?  

[Sheryl]

1 hour ago, jas007 said:

Here’s the situation in a nutshell:

 

I had surgery as an inpatient and was admitted to a preferred provider for one night. The hospital had previously submitted an “estimate of charges” for pre-approval and in response,

GeoBlue approved the amount for the surgery and related costs based on the hospital’s estimates.  The hospital would receive everything they asked for.
 

Anyway, all went well with the surgery, but when it was time to leave, the hospital billing office called my room and explained that since the actual charges exceeded the maximum amount set out in the guarantee of benefits letter, I would need to pay the difference of 21,000 baht or so.  No big deal, but I was under the impression that the terms of the agreement between the hospital (preferred provider) and Blue Cross provided that the patient’s bill would be paid in full for all covered expenses, and that claims for any amount due would be settled between the hospital and the insurer.

 

Anyway, rather than argue too much with the billing office, I just paid the bill.  I was told that when the final charges are finally settled and paid, that I would be reimbursed.  
 

Am I wrong in thinking that this is a matter usually settled between the hospital and the insurance company, and that the patient should not be presented with a bill at discharge?  

Yes, it should be settled between the hospital and the insurer. But there is not an agreement to just pay all covered costs. The hospital submits an estimate when requesting pre-authorization, and 

the GOP given will have been for a specific amount. The hospital needs to justify to the insurer why the total exceeds it. Should have notified the insurer as soon as it became apparent approved total was likely to be exceeded. 

 

Next time, be firm and don't pay anything (unless there is a deductible or specific costs you know the insurer will not cover). Tell hospital they must resolve the matter with the insurer.

 

Even in the supposedly top internatiomal hospitals in Thailsnd, I find the third part payment offices to be pretty weak/not very competent. And they will often try leaning on the patient for payment as the first approach since it saves them work.

 

If they underestimated  costs in the initial estimate they gave the insurer, that is their problem.

 

If something unexpected occurred that upped costs, they should have contacted the insurer at once to revise the GOP.

 

 

 

 

[Srikcir]

20 hours ago, jas007 said:

Am I wrong in thinking that this is a matter usually settled between the hospital and the insurance company, and that the patient should not be presented with a bill at discharge?  

For inpatient treatment you are correct. Prescription might be covered only 85%. You should have received a copy of the GOB that went to the hospital to that effect. 

For outpatient treatment you wouldn't be correct.

On either BCBS might reduce your benefit for annual deductible if not met. That wouldn't be in the GOB and you would have to settle personally with provider.

[Presnock]

20 hours ago, jas007 said:

Here’s the situation in a nutshell:

 

I had surgery as an inpatient and was admitted to a preferred provider for one night. The hospital had previously submitted an “estimate of charges” for pre-approval and in response,

GeoBlue approved the amount for the surgery and related costs based on the hospital’s estimates.  The hospital would receive everything they asked for.
 

Anyway, all went well with the surgery, but when it was time to leave, the hospital billing office called my room and explained that since the actual charges exceeded the maximum amount set out in the guarantee of benefits letter, I would need to pay the difference of 21,000 baht or so.  No big deal, but I was under the impression that the terms of the agreement between the hospital (preferred provider) and Blue Cross provided that the patient’s bill would be paid in full for all covered expenses, and that claims for any amount due would be settled between the hospital and the insurer.

 

Anyway, rather than argue too much with the billing office, I just paid the bill.  I was told that when the final charges are finally settled and paid, that I would be reimbursed.  
 

Am I wrong in thinking that this is a matter usually settled between the hospital and the insurance company, and that the patient should not be presented with a bill at discharge?  

You are correct, GEO blue obviously didn't read their 2024 brochure of overseas benefits.  It is very clear, hospitalization coverage says "unlimited" and ENGLISH meaning covered in full.  Even if you went to a non-prefered provider, it should also be covered in full!  I would contact bcbs immediately, complain and ask "wtf over".  The sole reason we probably have this very insurance is it supposedly covers everything without hassles.  I used to have the "wellness card" to from fepbku - had it for several years, responded every week doing my exercises, and reports to fepblu folks.  BUT it doesn't give the same

result as use in the US does in that no pharmacy in Thailand has the right code for one to use the card, even within the hospital, most times I had to pay up front and then claim it back on the card.  I have several hundred dollars and the purpose of the card is to buy OTC meds, and things at the pharmacies - a joke so I told them I wasn't interested in that anymore.  I am also on the advisory committee and will bring this up too.  Pls advise whatever they respond as it will affect my contact with fepblu.  thanks for this info too.

[Presnock]

18 hours ago, Sheryl said:

Yes, it should be settled between the hospital and the insurer. But there is not an agreement to just pay all covered costs. The hospital submits an estimate when requesting pre-authorization, and 

the GOP given will have been for a specific amount. The hospital needs to justify to the insurer why the total exceeds it. Should have notified the insurer as soon as it became apparent approved total was likely to be exceeded. 

 

Next time, be firm and don't pay anything (unless there is a deductible or specific costs you know the insurer will not cover). Tell hospital they must resolve the matter with the insurer.

 

Even in the supposedly top internatiomal hospitals in Thailsnd, I find the third part payment offices to be pretty weak/not very competent. And they will often try leaning on the patient for payment as the first approach since it saves them work.

 

If they underestimated  costs in the initial estimate they gave the insurer, that is their problem.

 

If something unexpected occurred that upped costs, they should have contacted the insurer at once to revise the GOP.

 

 

 

 

Yes, 2024 overseas benefits include "unlimited" for hospitalization with anything fully covered according to the benefits package.

 

[Sheryl]

11 minutes ago, Presnock said:

Yes, 2024 overseas benefits include "unlimited" for hospitalization with anything fully covered according to the benefits package.

 

That means there is no cap on hop much benefits you can receive. (As opposed to most private insurance which has a cap).

 

It does not mean that a hospital, on a specific admission,  has carte blanche.  The hospital has to submit estimated costs, these are reviewed for reasonableness and then a Guarantee of Payment (GOP, or GOB) is provided. For a specific amount. 

 

No insurer, ever, gives a hospital complete carte blanche without limit. If they did, they'd soon be bankrupt.

 

In this particular case, apparently the Guarantee was for the full amount of the hospital's estimate, but for some reason actual costs ran over.

 

The hospital needed to go back to the insurer and explain the difference, or else eat the cost themselves (since it was likely due to their own original mis-estimation or overcharging). Happens all the time. In most cases insurer will accept a small overrun once provided with the detailed bill. In others, they may demand an explanation.

 

OP was taken advantage of by hospital insurance staff who wanted to avoid work or did nto know what they were doing.

[jas007]

Presnock,

 

Thanks.  You’re right, I think, and I will write to the BCBS FEP carrier.  Apparently , there are lots of carriers operating under the BCBS banner, so I’ll have to figure out the correct people to contact.

 

In any event, the entire situation sort of irked me.  Not because 21,000 baht is a lot of money. It’s not. But what about the guy who uses a particular provider because that provider is a listed provider under the plan?  What about the guy who receives a Guarantee of Benefits letter indicating his obligation will be zero, and then goes ahead with the scheduled treatment, only to be hit with a request for a “deposit “ after the services have been provided?  What happens if a person just says NO? I’m sure some people simply wouldn’t be able to pay.  

 

I understand that the hospital just wants to be paid. It’s a business.  But that hospital also has a deal with the Plan as to direct billing and the patient’s obligations once admitted and treatment is completed. It’s a contract.  The hospital is paid directly and doesn’t have to try to collect from the patient, and in return the patient has no remaining obligation to the hospital once benefits are guaranteed. It’s simple for everyone concerned.

[jas007]

Sheryl,

 

I could have argued with the staff in the insurance office, but I would have been wasting my time.  Anyway, maybe I’m assuming too much.  I’m not sure how the system works in Thailand. One thing I know for sure is that trying to argue with a clerk in a hospital will get me nowhere. It will be one excuse after another.
 

I know a little bit about how certain things happen in the USA.
 

Take Medicare, for example.  A potential Medicare provider has to go through a series of steps to participate in the Medicare program.  Most doctors go through these steps, as do most hospitals and other providers.  In order to become a Medicare provider, they have to be properly licensed and certified under state law, they have to make an application to Medicare, and they have to supply supporting documentation. Depending on what type of services they provide, they may have an on site inspection of their premises.  And if they are approved, they get a Medicare provider number. When they then treat Medicare patients, Medicare will cover claims for approved care.  In some cases, the Medicare providers can also agree to “accept assignment.” That means the patient assigns his Medicare benefit to the provider, who is then allowed to bill claims directly to Medicare. As part of that deal with Medicare, the provider agrees to accept the payment received from Medicare as payment in full for the services or medical equipment provided.  The patient is out of the loop, so to speak.  Medicare claims filed in this manner are paid immediately, if properly coded.  Sometimes, Medicare will subsequently go back and review the submitted claims as part of its audit process.  And if Medicare determines that any particular claim should not have been paid, they will seek to recover that money as an overpayment. Sometimes, Medicare will find that the treatment provided was not medically necessary. Sometimes they’ll find that the particular services provided are not covered by Medicare at all. And sometimes they will find that the claims submitted are simply fraudulent.  That’s called Medicare fraud, and there’s a lot of it. 
 

In my mind, the process of becoming a listed provider under the FEP overseas plan probably works in a similar manner.  The hospital or provider enters into an agreement with the FEP plan, and as a part of that agreement, they agree to a direct billing arrangement. The patients obligation is zero, if that’s what is stated in the Guarantee of Benefits letter. The benefit to the hospital is that they are assured payment for covered services.

 

So it seems like the hospital wants the benefits that go along with being a listed provider and the benefit of direct billing, but they also want to keep the patient in the loop as a “backup.”  
 

 

 

[Sheryl]

1 hour ago, jas007 said:

The hospital or provider enters into an agreement with the FEP plan, and as a part of that agreement, they agree to a direct billing arrangement. The patients obligation is zero, if that’s what is stated in the Guarantee of Benefits letter. The benefit to the hospital is that they are assured payment for covered services.

Yes but they are assurred of payment based on the estimate they submitted prior to receiving the Guarantee. Apparently in your case the actual cost ran over by 21k. (Either that,  or the insurer, after seeing the final detailed bill, objected to items totalling 21k. Less likely. but possible especially if there was a long delay before the clerk talked to you). 

 

You don't "argue" with the clerk.  You just firmly tell them that they must work it out with the hospital. Full stop. 

 

Believe me, in my 30 years here I have encountered this over and over.  Very common in Thai hospitals. The least little issue and the first approach is to sound out the patient and see if they will pay. 

 

You will encounter it again.

 

 

[jas007]

I assume that the bill ran over the estimate because the actual cost was more than the estimate. Remember, an estimate is just that, an estimate.  I’m sure all parties would agree. How could it be anything other than that? It was prepared before any services were rendered. In any event, to say that the Guarantee of Benefits letter is binding only to the extent of the stated guarantee amount means that there really is no guarantee that all covered services will be paid, even though the guarantee letter itself suggests otherwise. What good does that do the patient?  “Here’s a Guarantee of Benefits” letter.  You might be insured, or you might only be partially insured.” That’s the gist of it. An illusory guarantee. 
 

The patient is in a vulnerable position. Services have been rendered and the hospital expects payment.  The patient will not be discharged unless the bill is paid.  The patient is an easy target in a vulnerable position.  
 

It seems to like the hospital wants all the benefits that it is entitled to as a listed provider, but does not want the obligation it probably agreed to as part of the agreement to be a listed provider.  The hospital is able to bill the insurer directly and is assured payment for all covered costs.  That’s a benefit for the hospital .  On the other hand, the patient is assured that payment will be made for covered charges. I do believe that this arrangement must be part of the contract between the hospital and FEP.  Why should the patient be pressed for payment of charges that are covered?  If the reasoning is that some of the charges submitted might not be covered for whatever reason, that means the patient has no real guarantee. It puts the burden of possibly having to file a claim back on the patient.  But that’s precisely why direct payment procedures were established, I’m afraid.  The patient wants a real guarantee, not an illusory one. 
 

Anyway, I paid the money because it was no big deal and I was in no position to argue.  In the future, I’ll know better than to expect appropriate treatment.

 

For what it’s worth, I currently have a whole stack of paperwork for various routine office visits and tests all performed at that hospital.  I have always settled the bills by paying directly, and I have never filed a claim.  My tolerance for nonsense claim forms is very low.  Almost zero. At some point, I might think about filing a claim, but I certainly wouldn’t do it for just a few hundred dollars.  I probably wouldn’t do it even for 21,000 baht.  I’m just aggravated at this situation because I don’t think it was handled properly. 

[kawikasudo]

This is off the subject. I am 73 and a retired civilian federal worker from Pearl Harbor Shipyard and have Kaiser and Medicare as my provider but been living in Pattaya for 20 years. I was advised to consider in open season to switch over to FepBlue. I don’t know any American federal workers around here so I’m asking you guys for your opinion since I’m already 73. Thank you!

[jas007]

11 minutes ago, kawikasudo said:

This is off the subject. I am 73 and a retired civilian federal worker from Pearl Harbor Shipyard and have Kaiser and Medicare as my provider but been living in Pattaya for 20 years. I was advised to consider in open season to switch over to FepBlue. I don’t know any American federal workers around here so I’m asking you guys for your opinion since I’m already 73. Thank you!

Did they say why you should make the switch?  The first thing to do is to compare the two benefit packages side by side.  See what seems to be the best.  What about the cost of each? Does that make a difference?

 

Remember, there’s an open season every year.  If you switch and don’t like the new company, I think you can always switch back during the next open season.

 

One thing that did change for the FepBlue program this year is the way the cost of prescription drugs are covered.  Members could opt to remain covered by FepBlue and its formulary, or, they could opt to have the same coverage as they would under Medicare Part D. I didn’t really look into it, as I don’t take any medications. That might be a factor for you.

[EVENKEEL]

I have Blue Cross/Blue Shield International which I kept after retiring from DOD. I've used it once at BPH for surgery which cost 350K. I didn't pay anything. Some of the follow up visits weren't covered 100% and I had to pat 1200 copay.

 

When I was released from Hospital they escorted me to the cashier, I wasn't sure what my cost would be but as it turned out, I didn't have a charge.

Edited 14 hours ago by EVENKEEL

[jas007]

All the outpatient visits and tests I usually just pay for out of pocket. They always give me a claim form, but I never bother with it.  Too much aggravation for me. Too little money. Life is too short.

[Sheryl]

3 hours ago, kawikasudo said:

This is off the subject. I am 73 and a retired civilian federal worker from Pearl Harbor Shipyard and have Kaiser and Medicare as my provider but been living in Pattaya for 20 years. I was advised to consider in open season to switch over to FepBlue. I don’t know any American federal workers around here so I’m asking you guys for your opinion since I’m already 73. Thank you!

Medicare will not cover you abroad and I doubt a Kaiser/Medicare plan would either...have you used it in Thailand?

 

FepBlue is better suited for coverage in Thailand. Probably why you were advised to seitch.

 

 

[jas007]

15 minutes ago, Sheryl said:

Medicare will not cover you abroad and I doubt a Kaiser/Medicare plan would either...have you used it in Thailand?

 

FepBlue is better suited for coverage in Thailand. Probably why you were advised to seitch.

 

 

I haven’t looked it up, but I think that some Medicare Advantage plans (Medicare Part C) actually cover overseas medical care.  I’m not sure of the particulars.  The Advantage plans use this additional coverage as an incentive to get people to switch. What I’m not sure about is whether a person without a U.S. address would be eligible to switch in the first place.

 

As a side note, based on what I’ve seen, I would never consider switching to an Advantage plan.  The way the plans make money is by denying as many claims as possible. They keep the premiums in any event.  

[Sheryl]

7 hours ago, jas007 said:

I haven’t looked it up, but I think that some Medicare Advantage plans (Medicare Part C) actually cover overseas medical care.  I’m not sure of the particulars.  The Advantage plans use this additional coverage as an incentive to get people to switch. What I’m not sure about is whether a person without a U.S. address would be eligible to switch in the first place.

 

 

 

Usually need not only a US address but an address in the plan area (usually a state) and be resident there at least 6 months of the year. 

[Presnock]

4 hours ago, kawikasudo said:

This is off the subject. I am 73 and a retired civilian federal worker from Pearl Harbor Shipyard and have Kaiser and Medicare as my provider but been living in Pattaya for 20 years. I was advised to consider in open season to switch over to FepBlue. I don’t know any American federal workers around here so I’m asking you guys for your opinion since I’m already 73. Thank you!

I have been a member since 1996 - costs keep going up but since UNCLE pays about twice as much as me for that policy, I can afford it...1st wife used it during fight against breast cancer and everything went smoothly as we were in the states during that period.  I haven't filed a claim in years but  probably will do so shortly for last year's/this year's daughter visits to hospital.  Previous overseas coverage office was great in providing letters but not so sure about this new one.  Will wait and see.  Many hospitals in Thailand are preferred providers so they should recognize the Fepblue anyway.