By DAVID TAFFET | Staff Writer

Bellos says insurer’s failure to pay claims affects 700 patients,endangers his practice

Dr. Nick Bellos

Last year, Dr. Nick Bellos stopped accepting Blue Cross/Blue Shield because of unpaid claims by the insurer, affecting about 700 patients. Some have been coming to him for 15 years.

Bellos has one of the largest private HIV practices in the country. Last May, he left the Blue Cross/Blue Shield network because the provider hadn’t paid almost $550,000 in claims, mainly for infusion services Bellos performs in the office.

Bellos said performing those services on site rather than sending his patients to a skilled nursing facility saves money for both the insurance company and his patients. Still, Blue Cross refuses to pay claims from 2008.

He met with his state representative and with the Texas Department of Insurance. Now he is pursuing legal alternatives and has sent his patients the bills that Blue Cross hasn’t paid. He hopes his patients and their employers can collect the money that the insurer has refused to pay him.

Bellos said it’s a breach of contract.

"We fulfilled our portion of the contract by providing the contracted services, and the patients and their employers fulfilled their portion of the contract by paying premiums," Bellos said.

"They want to pay us under a contract we signed in 2009 at about a third of the reimbursement we would have received in 2008," he said. "The rates for 2009 were never verified by our former CFO, and had I been told the 2009 rates, I would have never signed the contract."

Margaret Jarvis, a Blue Cross spokeswoman, said she couldn’t comment on specific instances due to confidentiality provisions in the company’s contract with Bellos. But Jarvis maintained that Blue Cross has paid claims that were properly submitted.

Because he couldn’t afford to provide services at one-third the rate he charged the previous year, Bellos left the network in May 2009.

Changing insurance providers is not an option for many of his patients because Blue Cross/Blue Shield administers the high-risk pool in Texas, which covers many people with HIV. Despite state funding support, this insurance has high monthly premiums and carries excessive out-of-pocket deductibles.

"If more doctors chose to drop BCBS because of reimbursement issues, where will these patients obtain care?" Bellos said.

Bellos’ practice employs 23 people. He has more staff in the billing department than in patient care. He’s purchased new equipment for his office to offer infusion services, X-rays and lab-draws. Not only does this save his patients time, but it limits their expenses to one co-pay for a visit.

Ironically, one of his biggest recurring expenses is more than $10,000 in monthly health insurance premiums to cover himself, his staff and their families. He insures through Aetna, the one company in Texas that offers partnership benefits to companies with fewer than 50 employees.

Bellos said he hasn’t taken a salary in three years.

But the billing problems are not just with Bellos’ office.

A pharmacist, who asked not be identified due to ongoing negotiations with Blue Cross, employs 15 people. He said Blue Cross reimburses him in 90 to 200 days.

"Our vendors want to be paid in 10 days," Bellos said.

The pharmacist said that often, if a number of medications are included on a claim, Blue Cross pays the less expensive items and ignores the most expensive ones.

He said if he charges for 120 units of an expensive medication, the insurer will pay for 20. The pharmacist said this has happened repeatedly.

Last year, he began paying an outside agency $250,000 a year to do his billing and try to collect from Blue Cross.

What explanation does the insurance company offer for withholding payments?

"There’s always a reason," Bellos said.

He said the one he’s heard the most recently is that Blue Cross never received the claim. Despite having paid part of a claim, as in the case with the pharmacist, or having signed a return receipt for the claim, they insist no claim was filed.

"If it’s a big claim, you’re going to through hell to get paid," the pharmacist said.

Bellos said another tactic used by Blue Cross is requesting a copy of medical records. So he began sending medical records with every claim submitted to the insurer. Copying records and paying for return receipts has increased his billing costs.

Blue Cross also sometimes returns claims and requests that they be filled out differently, Bellos said. Among the suggestions from Blue Cross was to leave out certain billing codes. That would allow the insurance company to substitute codes that either reflect the lower 2009 rates or insert codes that violate the law.

Bellos has refused to submit claims with blank billing codes.

In most cases, the Texas Department of Insurance can’t regulate Blue Cross, because the insurer is the administrator for many companies that self-insure. Those fall under the U.S. Department of Labor.

Bellos is hoping that some of his patients will take the bills he’s sent to their HR departments to demand that the insurer cover the claims.

Jarvis, the Blue Cross spokeswoman, responded in an e-mail to requests for comment from Dallas Voice.

"Due to the confidentiality provisions of the contract we had with Dr. Bellos, Blue Cross and Blue Shield of Texas (BCBSTX) is not able to discuss specific provider information. Although we cannot speak to the specifics of this instance, I will say that we followed up with the physician to clarify the status of his outstanding claims and paid for the claims that were properly submitted," she wrote.

"During our 80-year history, Blue Cross has worked hard to maintain the positive, collaborative relationships we have established with physicians and hospitals. For instance, we developed and staff an Office of Physician Advocacy dedicated to addressing network physician concerns and fostering robust communication with the physician community. We have the largest health care provider network in the state with more than 40,000 physicians and 400 hospitals, and this network continues to grow every year. As a result, we believe physicians in general see us as a good partner in caring for members and patients."

So is Blue Cross singling Bellos out? While health care providers that work with Bellos said they’re also having problems collecting from the insurer, other doctors interviewed for this article said they aren’t.

Dr. Diane Litke is an orthopedic surgeon in

Richardson. She was surprised to learn of the trouble Bellos is having.

She said, "In my practice, Blue Cross is one of the better ones."

Dr. Steven Pounders is another Oak Lawn internist with a large HIV practice. His office said they don’t have a particular problem with Blue Cross. However, they also don’t perform in-office infusion services that have caused most of the problems for Bellos.

Bellos noted that profits for health insurance companies have soared, from 13 percent in 2004 to 37 percent in 2009. In other words, in 2004, if the average premium was $300, the insurance company kept $39 as profit. Five years later, with the average premium at more than $500, they keep $185 per month.

Bellos also wondered how the average person in the Texas assigned risk pool affords that coverage. Those patients pay $900 per month in premiums and have a $5,000 annual deductible. Even if Blue Cross paid all of their claims, they would have $15,800 in out-of-pocket expenses.

An Oak Lawn man who has been a patient of Bellos for 10 years continues to see him and pays for visits out-of-pocket. He asked not to be identified because of the ongoing billing problems with Blue Cross that his company is trying to help resolve.

Bellos referred the patient to a dermatologist last year for a necessary treatment. That office pre-approved the services with Blue Cross, and the patient paid his co-pay at the time of his first visit.

On his second visit, the dermatologist asked how he was going to pay the $300 balance the insurer had rejected.

He also has an unpaid bill for services provided by Bellos. But, he said, "I don’t want to change doctors. I can’t afford to change employers. It’s less stressful for me to come up with a few hundred extra dollars and pay what I wasn’t expecting and shouldn’t have to pay."

But, he said, that’s probably exactly what Blue Cross wanted.

This article appeared in the Dallas Voice print edition March 19, 2010.anonymizer-besplatno.ruопределить айпи сайта