Trapped by Blue Cross’s liesBefore you’re treated, they say doctors are in their network. Afterward, they pay nada, saying many of those doctors aren’t in-network.
Published on June 24, 2021
By Randall Rose
Blue Cross of Rhode Island is running a scam. When they offer you health insurance plans to buy, they tell you they have lots of Rhode Island doctors, or “providers”, in their network. But depending on what plan you pick, that may not be true. If you pick the wrong plan, you may find out later that a huge number of doctors who they said would be in-network aren’t. And you only find that out after they stick you with the bill.
No heart surgeons
When I learned I need open-heart surgery, I found I had a problem with my Blue Cross plan: they have absolutely no heart surgeons in-network. A doctor recommended a surgeon to me, but this surgeon, like all other heart surgeons, is outside the plan’s network, and the plan says (link) that out-of-network care is not covered. Nor can I change to another plan. I’m publishing my experience so people can hear about Blue Cross’s lies.
Blue Cross is offering 11 Obamacare-style health insurance plans to consumers, not counting dental plans and Medicare plans. They have acquired a reputation for having a lot of providers in their network, but what they don’t reveal to you in advance is that two of their 11 plans don’t use the usual, big Blue Cross network of Rhode Island providers. The 2 plans whose names begin with “BlueCHiP Direct” have far fewer providers in-network. That is why, for instance, I have no heart surgeons in-network for me even though I need lifesaving surgery.
I’ve seen Blue Cross flat-out lie to customers about this when the customers are buying plans. The fact that their BlueCHiP Direct plans have a much smaller Rhode Island network, compared to other Blue Cross plans, is something they don’t seem to want to publicly announce. They falsely assure customers of the opposite while consumers are buying plans. But also, Blue Cross deceives doctors and other providers on this subject too.
Blue Cross can give providers a false impression, telling the provider or the provider’s staff that the provider is in-network for Blue Cross, while not telling them that actually, they’re considered out-of-network where some Blue Cross plans are concerned. Does it matter when Blue Cross misleads doctors on this? Yes, it does. When Blue Cross says to a provider or to staff that they’re in-network, and fails to warn them “Actually, you won’t be considered to be in-network for some Blue Cross plans”, you have to expect that will lead to the provider’s office telling potential patients point-blank that they are in the Blue Cross network. So the patient thinks it’s safe to be treated by this provider because the provider is in-network. But if the patient has a BlueCHiP Direct plan, neither the patient nor the provider nor the provider’s staff may be told beforehand about the key fact: this plan has a much smaller network than most Blue Cross plans. I’ve seen this happen. The patient comes in for treatment, expecting that Blue Cross will pay, and then when it goes to billing Blue Cross eventually sends the patient a message: “K83 – Services provided by non-network providers are not covered by contract”, and pays nothing.
I have documentation of how Blue Cross deceived a provider. This provider applied to be in Blue Cross’s network of providers, and was told he was accepted. Blue Cross of Rhode Island made him think that applying and being accepted meant that he would be in-network for all of their patients. That’s not actually true, but it is what they implied. One email message he got from Blue Cross spoke to him about his “request to become a participating Provider in the Blue Cross & Blue Shield of Rhode Island (BCBSRI) network. The BCBSRI Credentialing Committee has approved your request for Participation….” Since they said that he had been approved to be in “the” Blue Cross network, their word “the” clearly indicates that they have just 1 Blue Cross network for Rhode Island providers. So he, very reasonably, concluded he would be in-network for my plan from Blue Cross, and he told me so. But then after I got treatment from him, Blue Cross refused to pay: “K83 – Services provided by non-network providers are not covered by contract.”
This provider never knew that Blue Cross would consider him to be in-network for only a limited set of Blue Cross patients, until I got treated by him and Blue Cross refused to pay. He had gotten multiple communications from Blue Cross, but until the point when my medical costs were billed, none of the communications he had gotten from Blue Cross did anything to reverse or reject the original message that he was in “the” Blue Cross network, which had implied that there was only one Blue Cross network. I get the impression that Blue Cross may not want patients or providers to know that there is more than one Blue Cross network while patients and providers are making their initial decisions. What I’ve found is that Blue Cross will unexpectedly refuse to pay even though everyone was led by Blue Cross to believe that the patients would get in-network coverage for these providers.
A narrow network
I’ve called Blue Cross to complain, and they told me over the phone that my particular plan has a “narrow” network or list of doctors. That was the first clear message from them that the plan has a smaller network than some of their other plans. They said it only orally, not in writing, and only after I called their service line. But it wasn’t until I needed open-heart surgery, which I found out while I was on this Blue Cross plan, that I discovered how truly narrow the network is.
When Blue Cross people talk to me, they often say that I can go to their online “find a doctor” service and find out what doctors are considered in-network. I’ve tried doing that. For the specialty of cardiovascular surgery, which is the only specialty covering the surgery I need, their website listed just one surgeon in Rhode Island on my plan: Dr. Steven Milman. HE DOESN’T DO HEART SURGERY. Instead he does chest surgery that doesn’t involve the heart. You would think that Blue Cross would have not just one, but a number of heart surgeons available to choose from, and they do if you buy one of the better Blue Cross plans. But if you pick a BlueCHiP Direct plan, you find that the only “cardiovascular surgeon” who’s in-network is Dr. Milman, and he’s not even in the heart-surgery field.
Blue Cross’s salesforce
Just as I quoted the way Blue Cross deceives providers, I’ll also quote the way Blue Cross deceives customers when customers are in the process of buying plans. Blue Cross of Rhode Island has a chain of retail stores where Rhode Islanders can shop for health plans. You can walk into the stores and talk to salespeople who will discuss Blue Cross’s different health insurance plans. These stores are called “Your Blue Store”, and they have a total of 4 stores across Rhode Island – a higher number of stores than they have heart surgeons on my plan. I tried talking to a Blue Cross salesperson at the store. I didn’t give my real identity because I didn’t want my earlier complaints to Blue Cross to affect things, and I said I didn’t have health insurance yet and wanted to look at Blue Cross plans. But I handled everything in a neutral way, without trying to steer the salesperson into overstating or understating their coverage. While giving me brochures and talking about the different plans, the salesperson said that most doctors in Rhode Island are in the Blue Cross network. And when discussing a BlueCHiP Direct plan – which is really my current plan, though I didn’t tell them that – the salesperson said that it doesn’t include doctors outside Rhode Island, but that inside Rhode Island, it has the same network of Rhode Island doctors as the other Blue Cross plans. This isn’t actually true! To make sure this is really what Blue Cross wants to say, I asked the salesperson again, and they repeated their assurance that Blue Cross has the same Rhode Island doctors in-network for the BlueCHiP Direct plan as they do for their other plans.
It’s not just about me or just about one person. For myself, by the time I went into the retail store, I had already figured out enough so that I wasn’t fooled. But my experience at “Your Blue Store” shows that they are deceiving other customers too: when they told me these false things in their store, it indicates Blue Cross is also telling lies to their other customers who are shopping for Blue Cross insurance in stores.
The way they price their Obamacare plans makes it worse. Some of the Blue Cross plans are “health savings account” plans that really don’t cover much, although they do provide tax breaks. The 2 cheapest Obamacare plans that Blue Cross offers are “health savings account” plans that pay for almost no medical treatment unless you first spend thousands and thousands of dollars out of your pocket – they have a strict deductible of over $4,000. Not many people would like these very cheap plans because they cover so little. But apart from these 2 super-cheap plans, the least expensive Obamacare plan that Blue Cross offers is one of their BlueCHiP Direct plans. Given their price structure, that BlueCHiP Direct plan looks like a great option. The problem with it is that it has just a narrow network of doctors, but they don’t tell you that when you’re buying it. If you’re looking for an affordable plan that still pays for a substantial amount of medical expenses, it’s plausible that you’ll think that a BlueCHiP Direct plan is a good deal for you, because Blue Cross never tells you that this plan’s network is not as big as most Blue Cross plans. The false statements that Blue Cross makes to potential customers help sell patients on this plan.
Blue Cross’s inflated numbers
The deception isn’t limited to customers who go to Blue Cross’s retail store. You can also shop for plans on Blue Cross’s website. Again, the website never tells you that some of their plans have fewer Rhode Island doctors than other plans. Instead, when you shop on the website and look at BlueCHiP Direct plans, the website posts false, overstated numbers about how many doctors are covered, so that customers think they’ll be getting access to far more doctors than they’ll really have.
The Blue Cross website is deceptive both in its words and in the false numbers it gives. It says that a customer on a BlueCHiP Direct plan “uses our local RI network” of providers, but it leaves the impression that this network includes all the providers in the state who have been accepted by Blue Cross of Rhode Island, because it never says they have more than one network where Rhode Island doctors are concerned. As far as numbers go, the Blue Cross website says prominently that BlueCHiP Direct plans have “about 1,400 primary care doctors, and about 3,300 specialty doctors.” This is not true! To find more accurate numbers, I looked at Blue Cross’s online listing of providers belonging to the BlueCHiP Direct network – which is not all that easy to use, but at least gives specific details. I started by checking whether they really have “about 1,400 primary care doctors”. In their online listing, they show various categories of primary-care providers such as “Adult Primary Care”, “Family Medicine”,”Nurse Practitioner – Primary Care”, and “All PCPs”, and many primary-care providers are listed in more than one category. If you look at the number of providers listed in a given category, and then add the numbers for each category together, you do indeed get a big total of about 1,400 for all the primary-care categories, but that is only because some primary-care providers are listed in multiple categories and the same person ends up counted multiple times. In actuality, instead of their claimed number of “about 1,400 primary care doctors”, they really have only about 600 if you count each doctor only once, and even if you add in the nurse practitioners alongside the doctors, you still only get about 850.
So the exaggerated number of “primary care doctors” that they show you, when you’re thinking of buying, is more or less double the number of primary providers they truly have. I managed to work out that the actual number was about 600 primary-care doctors and about 850 primary-care providers, but that’s not something you can find out easily. I had to spend a lot of time looking through Blue Cross’s online listings and analyzing them.
Similarly, the Blue Cross website exaggerates in saying that BlueCHiP Direct plans have “about 3,300 specialty doctors”. After laboriously checking, I did find that they had about 3,300 if you count all members of their network in no matter what field, but that number includes primary-care providers too. Instead of Blue Cross’s claim that BlueCHiP Direct plans have “about 1,400 primary care doctors and about 3,300 specialty doctors”, they really have only about 850 primary-care providers and about 2,400 specialty providers. And even those smaller numbers include hundreds and hundreds of nurse practitioners, physician assistants, health-care companies, and members of other health-related specialties who are not really, as Blue Cross claims, “doctors”.
I know that if I get to go to the hospital for heart surgery, I will want to bring a printed list with me of the providers who are in-network for my Blue Cross plan, so that the hospital doesn’t surprise-bill me for treatment by providers who are outside my network. So, I called Blue Cross in May and asked them to mail me a printed list of all the providers in my network. They said they would. I had to call them back repeatedly and got more of a runaround – one time they said that yes, they had already mailed it on May 14, then when I called again after it hadn’t arrived they said there was a note in my file dated May 14 about why they hadn’t sent it, then they said that they couldn’t send the list of providers either by mail or by email because it was well over their 70-page limit for sending out info, and then finally they said they were mailing me printed lists of all Rhode Island providers on my network within 30 miles of my Providence zip code, broken up into multiple 70-page documents. I got the printed documents, which included providers as far away as Wakefield and Richmond but left out about half of South County. The documents showed that Blue Cross had fewer than 1,000 providers in my plan’s network – and even if you add the remaining providers from South County, that won’t be more than a few hundred more. So the printed listings they mailed me show even fewer providers than Blue Cross’s online listing does. I don’t know which one to trust.
When I talked with a Blue Cross salesperson in their in-person retail store, I had been told that the network for my plan would include “most” Rhode Island doctors. Again, not actually true. I checked the RI Department of Health website, which shows a little over 5,300 doctors in the state who have a currently active M.D. license. At least where M.D.’s are concerned, the network for my Blue Cross plan does not include “most” of the doctors as they claim – it’s not even close to half. The plan’s network only includes about one-quarter of the doctors who have an active M.D. license. For some specialties, the plan’s network is okay, but for other specialties, like heart surgery, it’s terrible. Another example is if you’re looking for a marriage/family therapist, where my plan only offers 3 providers to choose from, while other Blue Cross plans let you choose from nearly a hundred.
Even for those who don’t interact directly with Blue Cross when buying, Blue Cross’s deceptions matter. I originally purchased my plan by shopping online through HealthSourceRI, without going to the Blue Cross store. I was careful to compare different plans by looking at how much each plan was willing to pay for each different type of medical care. Here is a link to the Summary of Benefits document for my plan, available through HealthSourceRI, which gives a point-by-point outline of what the plan is supposed to cover. Nothing in the Summary of Benefits says that this plan has a smaller network than other Blue Cross plans. After I bought the plan, when I called Blue Cross to complain, I was finally told it had a “narrow network”, so I asked the Blue Cross person where it says that in the Summary of Benefits. She admitted it wasn’t there, and referred me instead to a different web page that said this plan has a “tailored network”. Of course, even if Blue Cross had told me while buying that the plan has a “tailored network”, that very much fails to say anything about the network being unusually small or about the network being different from the networks that Blue Cross offers for other plans.
When I looked for plans on HealthSourceRI, the main reason why I was willing to buy from Blue Cross was simple. It was because the providers I expected to deal with had told me earlier that they would be in-network for Blue Cross, and I had also noticed myself over the years that plenty of providers are willing to say they are in the Blue Cross network. These providers meant to tell me the truth, and in the end, they said it because Blue Cross had notified them that they would be in-network for Blue Cross, as if there was only one Blue Cross network. And when Blue Cross tells doctors they are in-network, not mentioning that these doctors will be considered out-of-network for some Blue Cross plans, Blue Cross is itself responsible for this false message spreading from doctors to consumers. Like many consumers would, I trusted what I heard from doctors about their insurance network status, and that was why I felt that buying a Blue Cross plan would give me a wide enough network of doctors. Think about it – when you feel willing to buy from Blue Cross insurance, is that because you believe they’ll be caring and fair in paying up for your medical treatment like a great insurance company would, or is it more because the word has gone around that many doctors are in-network for Blue Cross? Is the value of the Blue Cross brand built on Blue Cross producing the impression that most doctors will be in your network when you buy from Blue Cross?
There would have been a way to treat me fairly when I was buying insurance on HealthSourceRI. If the information that Blue Cross provided on HealthSourceRI had prominently proclaimed “WARNING: This Blue Cross plan will sometimes treat providers as out-of-network even when these providers have been told by Blue Cross that they are in-network”, or something like that, then I would have known better and made a truly informed decision. Because there was no such warning, I couldn’t help relying on what I had heard from my specific providers based on what they had heard from Blue Cross, and I ended up buying the plan on false grounds.
I would think that Blue Cross has gotten authorization from the state government to sell some plans that have considerably smaller networks than the other Blue Cross plans. That could be fine if Blue Cross did it honestly with everything clear and upfront in advance for the consumer, but I doubt that Blue Cross told the state government it was going to mislead or outright lie to people about this. I have never seen Blue Cross reveal in writing the key fact that some of its plans have a smaller network than other plans. That’s a point that they never explicitly make except when you actively question them first, and it is significant that they are so cagey about this. Blue Cross’s conduct seems very much like what you would expect them to do if they wanted to make money from the false impression that their BlueCHiP Direct plans have as wide a network as their other plans. And whether they intended to deceive or not, the fact that their conduct is indistinguishable from the conduct of a business that deliberately profits by misleading consumers shows that this conduct shouldn’t be allowed. Blue Cross should not be allowed to profit by refusing to pay medical bills when, in the end, it was Blue Cross themselves who created the wrong impression in the minds of prospective customers that bills from these providers would be in-network.
I’ve repeatedly seen Blue Cross reject bills entirely from providers who were told they were in-network. It’s not as if Blue Cross says that they’ll pay part of the bill, or that they’ll put the bill towards the deductible. Instead, Blue Cross won’t do anything helpful with the bill: you don’t get the negotiated insurance discount, you don’t get any credit of any kind. Sometimes if I complain, Blue Cross will agree to pay something to the provider as a “one-time exception”, but they also tell me that this won’t last long and that at some point they will go back to paying nada for this provider. Perhaps Blue Cross would be willing to offer me something like a one-time exception so that I can get heart surgery, but that’s far from being enough. A one-time exception just for my heart surgeon won’t cover all the treatment I need, and it doesn’t help the other customers who have been deceived by Blue Cross. I am not looking for Blue Cross to offer more of these one-time exceptions, but for them to have to fix what they did wrong.
To be clear, I don’t want just something for myself. People who buy this sort of plan from Blue Cross, and were led to think that the plan would cover a wider range of doctors, need to get coverage that includes the same network of doctors as other Blue Cross plans. So, it seems, others are in the same boat as I am. I hope to publish an update or a followup at some point, and I can be reached at firstname.lastname@example.org.
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