Working together to improve the member-provider experience: Member Concerns about “Up front” Payments

July 6, 2018

Blue Cross Blue Shield of New Mexico (BCBSNM) is focused on improving our members’ experience when they access care. On occasion, a member or their representative may call BCBSNM to voice concerns and/or dissatisfaction with a provider or care received. The BCBSNM Quality and Accreditation Department is responsible for processing complaints from commercial and marketplace members regarding the quality of care and/or the quality of service that they receive from their BCBSNM participating providers. These complaints are investigated and tracked to identify trends and ideas to improve the member-provider experience.

BCBSNM will publish a series of articles throughout this year to address some of our members’ most frequent concerns and remind providers of some of their related contractual obligations. We hope that we can work together with you and your staff to improve the care that you furnish to your patients (our members).

This month we will look at the following member concern: “May my provider require an “up front” payment?”

Members are often surprised when they are asked for a payment “up front” before services are rendered. Taking time to explain your office process as well as encouraging members to call a BCBSNM Customer Advocate to explain member share (i.e., copay, coinsurance, deductible), may help alleviate concern. Let’s look at the Blues Provider Reference Manual 2018 for contractual requirements.

Blues Provider Reference Manual 2018, Section 5, Professional Provider Reimbursement ,5.5 Member Share – Copay, Coinsurance, and Deductibles

Member Share
Providers contracted with BCBSNM must collect member share. It should be collected at the time the service is provided. Check the member’s ID card for the proper member share amount to collect. If you are unaware of the status of the deductible, collect 10 percent of the service being provided. You may have to refund the member when the Provider Claims Summary arrives and you can determine the exact member share. Member share is inclusive of State gross receipts tax, if applicable.

Office Member Share
An office member share is usually required for all office visits for which your office would ordinarily generate a charge, including blood pressure checks, educational sessions with a nutritionist, physical therapy, etc. If a charge is not generated for a visit, no member share should be collected.
Do not collect an office member share for non-surgical diagnostic procedures when there are no other office visit charges associated with those procedures. This includes lab, X-rays, mammograms, audiograms, and EKGs.

Below are some recommendations that may assist your patients, our members, in understanding their member share and anticipate out-of-pocket expenses.

Recommendations :

  1. Encourage your patients to be aware of their coverage, benefits and networks. A call to a BCBSNM Customer Service Advocate (CSA) before services are furnished to understand payment requirements and the anticipated “up front” payment is beneficial.
    Numbers to reach BCBSNM customer service are found on the back of the member’s BCBSNM ID card. If a member does not have their BCBSNM card, they may call:
    Commercial members: 1-800-432-0750
    Marketplace members: 1-866-236-1702
    Medicare Advantage members: 1-877-774-8592
  2. Should the member’s share be significant, please notify the member prior to the appointment to allow maximal time for financial planning.
  3. BCBSNM Provider Network Representatives are available to assist contracted providers:
    Monday - Friday, 8 a.m. to 4 p.m. Phone: (505) 837-8800 or toll free at 1-800-567-8540
    Fax: 1-866-290-7718

Remember, as a contracted provider, you are required to use other contracted providers to meet your patients’, our members’, covered health care needs. BCBSNM Network Representatives can tell you if another provider is contracted with BCBSNM for your patient’s particular BCBSNM health plan.