Blue Cross PPO
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Blue Cross PPO
I am trying to find a pediatrician for my daughter and the two
main pediatric offices in the East Bay don't accept my insurance
plan - Blue Cross PPO. I find it unacceptable that the plan I
am paying monthly to have, won't provide care at either of the
two major pediatric offices in my neighborhood. Who do I
complain to -- the insurance, the doctors? I've tried asking my
husbands employer if we can switch to an HMO plan, but that is
not an option. Any ideas out there??
- I miss Berkeley Pediatrics
We are on Blue Cross PPO and see the physicians at the Pediatric
Medical Group in Berkeley (2320 Woolsey). We've been very happy
with everyone in this office, and we think the world of them!
I am a physician in Berkeley who does not accept Blue Cross PPO,
and I understand your frustration about having insurance with
this PPO. Most medical offices who drop their contracts with
this carrier do so because the carrier pays equal or less than
Medi-cal rates to the medical providers. I don't suggest
complaining to the doctor's about it, you can rest assured that
they all attempted to negotiate a fair reimbursement rate with
Blue Cross but were unsuccessful in doing so. No medical
provider drops these contracts easily; we all know! we are
affecting our patients when we do.
If this insurance is through the workplace, you should be
contacting your human resources department about the inadequacy
of the medical coverage they are purchasing for you. Complain
also to Blue Cross. Ask them what they reimburse the physicians
who are contracted with them. They will probably tell you that
that is proprietary information. Rememember, you and your
workplace are the consumers, should you be purchasing a product
without knowing what you are buying?
Lastly, fight for the opportunity to switch plans. Good Luck
We had this problem, too, just after Berkeley Peds. dropped Blue Cross
PPO. The doctors will tell you to blame the insurance company; the
insurance company will tell you to blame the doctors. Truth is, they
failed to negotiate after a certain point. It's been several years
I have not heard anything getting any better. We transferred to
Medical Group, and after a couple of years, I can tell you I am so glad
we switched! I like this office much better, and it's a huge relief to
able to concentrate on the health of my child rather than the battles
between billing and insurance.
I understand your frustration. We ran into that when my
husband left his job and we h! ad to change our health plan.
We now have Blue Cross PPO and I was very disappointed
to discover that Berkeley Pediatrics didn't accept Blue
Cross. I had Dr. Franks, who I loved, and she said that they
stopped accepting Blue Cross because they were having
problems with them. It sounds to me like you would have to
complain to the medical group or docter. But I don't think you
can really achieve anything. They've made their decision. I
did discover Kiwi Pediatrics takes Blue Cross. Both Dr.
Kittams and Dr. Winoukur were recommended to me by Dr.
Franks. We use the practice on San Pablo Ave. They have
great nurse practioners there. We are happy with them. It is
hard to swithch docters when you are happy with who you've
got. Some people love their docters so much that they are
willing to pay a higher price if their insurance doesn't cover.
Check out Kiwi. They have two offices, one on Alcatraz Ave
652-1720, and one on San! Pablo Ave, near Gilman, 524-
9400. Good luck.
My daughter's healthplan is also Blue Cross PPO. I have found
them easy to work with. We currently go to Primary Pediatrics in
Oakland near Summit Hospital. The address is 411 30th St. Ste.
212. There are many good doctors in the practice. We have just
started seeing Laura Saldivar, who we really like. The phone
number is 510-433-1040. It is usally easy to get an appointment.
They do drop-in almost most mornings, including saturday until
11am. And the receptionist and nurses are very personable.
[editor] related discussion:
Pediatricians, New Patients and HMOs
We are considering changing our health insurance from Kaiser to
a Blue Cross PPO plan with a high deductible. Kaiser has
raised our premiums quite a bit, and we would save a
significant amount of money on premiums if we do. I wondering
about people's experiences with Blue Cross, if they are able to
find providers and if they have had trouble with getting
medical services approved. I have looked on the website and
have not found info about Blue Cross.
We learned to avoid Blue Cross --even the PPO -- when we
discovered how many doctors wouldn't accept it, and how many
were closing down their relationships with Blue Cross. For years
now, we have had the Blue *Shield* PP0, with a high deductible.
Many doctors take it and we have had no problem getting
approvals for what our docs want to do.
We have had Blue Cross through my employer for the past two
years. Prior to that we had Blue Cross through my husband's
employer. Know that every blue cross plan is a little
different. So, for example, doctor's visits that are
completely covered under my current plan were not necessarily
covered by my husband's. Your best bet is to look at all the
small writing in your plan proposal and to call their customer
service department with specific questions. Try to predict
what you might need to have done and ask if they will cover
it. For example: ''Will you cover an ultrasound for my 20-week
pregnancy check-up?'' ''Does your prescription plan cover all
drugs prescribed or only those prescribed by my primary
physician?'' ''Can I see any physician on the list or do I need
to get approval from my primary care doc first?''
I have the Blue Cross PPO plan with the $2000 deductible. I
have an individual plan; I don't know if it is better with a
I wish -- oh how I wish -- I had switched to Blue Shield before
I got pregnant. Blue Cross PPO pays very poorly to
pediatricians and so a bunch of very good Berkeley
pediatricians won't take BC PPO.
I've not had any problems finding physicians for me -- OB,
oncology, etc. -- that take BC PPO.
I've done benefits for many many years. The really short
version is, a PPO plan is always a good idea if you want
flexibility in your choice of doctors and services, but you will
have to pay some part of the visit or service depending upon the
PPO (i.e., 100% innetwork/80% out, etc.). I'd say Blue Cross is
fine, they have some of same annoying internal procedures as any
other PPO. Just be sure you follow the plan summary and pick
physicians in the Blue Cross network for maximum coverage. The
good news is, you'll notice when you make an appt at a
physician's office, the clerk will perk up when you say PPO
instead of HMO.
You may remember my posting from a couple months back when my
husband's company dumped our carrier (HealthNet) & had to
choose between Blue Cross HMO, Blue Cross PPO & Kaiser. After
reading all of the helpful responses & asking around, we signed
on with Kaiser & are SO-O-O-O glad we did!
What's right for you probably depends on your situation. If
you're young & healthy & don't have any prescription
medications, don't visit the doctor very often, don't have kids
AND/OR you have specific doctors outside of Kaiser whom you
know & trust & really want to work with, then Blue Cross PPO
could be a good choice, since most doctors in the area seem to
accept the plan. Back when my husband & I were young & self-
employed & didn't have kids & couldn't afford anything else,
Blue Cross PPO worked out great for us.
But overall, I recommend sticking with Kaiser. The monthly
savings on your premium may not be worth the higher
deductibles, copayments, & costs for prescription medications
if something changes in your life like a pregnancy or the onset
of some other condition that requires more doctor visits than
you were counting on.
Also, if you're used to the way Kaiser coordinates your medical
care, keeps track of your medical records & prescriptions, &
generally has basic stuff like flu shots in stock so you can
just walk in & get one, etc. you might find other Healthcare
providers to be a major hassle. Unless you know a doctor around
here, picking a primary care physician is like closing your
eyes & randomly pointing to a name in the yellow pages. In my
experience with other healthcare providers, including Blue
Cross, Aetna & Healthnet HMOs & PPOs, the right hand never
seems to know what the other hand is doing or what's covered &
what's not, etc.
I've had a Blue Cross PPO on and off for 15 years or so and it's
worked well for me. They've covered a few knee surgeries and
the associated bills without any problems. Currently, I have a
Blue Cross PPO plan through work. My wife was insistant on a
PPO plan (rather than Kaiser or an HMO) so we could go to any
doctor we wanted. We've had no problems with choosing/finding
doctors and services. No problems with getting procedures
approved (like sonograms and other baby-related tests). They
even cover a few visits for accupuncture each year.
A few caveats, however. Double check to see if the doctor(s)
you want to see accept Blue Cross. For example, the doctors
office I've been going to for years (Alta Bates Medical
Associates in Berkeley/Orinda) does not accept the Blue Cross
PPO (at least as of my last visit a few months ago). This means
I must pay for services up front, then get reimbursed from Blue
Cross at their rate, which means more out-of-pocket expense to
me than just the co-pay.
Also, take a close look at the fine print. Look at the
exclusions to make sure you're covered for everything you want
to be covered for. Also, you will have a co-pay each visit, and
a deductable up to a point, and a portion of the bill after
that. Look at your typical demand for medical services in a
year and figure out your total out of pocket expenses. Frankly,
I'd be surprised if it was less than Kaiser's total cost (at
work, Kaiser's monthly premium is a few hundred dollars less
than the Blue Cross PPO with a 2000 deductable). For us, the
choice and flexibility of the PPO is worth the cost of the PPO.
Blue Cross has seemed to work fine for me. I've had it for about
5 years and they have always been right on with payment for any
treatment that i've had. There are a few caveats to this: I have
an HMO which Brown & Toland manages. I have had more problems
with Brown and Toland and none to speak of with Blue Cross. I
can use a vast array of doctors, many of whom are excellent and
very caring practioners.
My husband's company closed down 6 weeks ago and at
that time we applied for private health insurance online
through eHealthInsurance and chose BlueCross (which we
had already had through his former employer). Six weeks
later, ie now - today, we have received an email saying we
are rejected for unspecified reasons and will get a letter
about it sometime. We have no pre existing conditions in the
family and virtually no health issues whatsoever!
We are furious and dumbfounded, and don't really
understand what do do now. We are already no longer
covered and don't want to risk waiting another six weeks to
find out the result of another blind application, but also can't
afford to pay the Cobra ''back 2 months'' of $700.00 per
month. Please any advice about this would be so helpful.
What should we do? How can we get honest answers and
Last year, my husband and I were also rejected when we applied
independently for insurance, also through ehealthinsurance.com
(but with Blue Shield). It was a huge learning experience.
Mainly, when you apply independently for health insurance they
can reject you for any small/large reason -- or no reason at
all (which has been happening more and more lately since the
economy is bad and insurance companies are taking fewer risks).
Whereas when you apply through a group -- insurance companies
care less about you as an individual because they figure most
in the group will be healthy and a few sick. My advice is to
fight their decision. Once you get their letter, call the 800
number on it, and try to get as much information about the
reason for your rejection as possible. Then write a formal
letter asking to appeal their decision and your reasons why.
Then continue to call and follow-up with them until you hear
back on the appeal (can take 6 weeks to 3 months). But very few
people appeal and there's a good chance they'll reverse their
decision if you bug them. They reversed their decision for my
husband and I but, I admit, the experience was somewhat
degrading and eye-opening on the whole health insurance world.
We've been through something similar to this twice. What we
learned was Get an insurance broker. One who handles several
insurance companies is best, because she or he can help you
maneuver through the options and the application, get you over
the various hurdles, and tell you why one company's deal is
better for you than some others'. Also, now that you've been
denied, when you apply to other comnpanies, you have to admit
that fact. This will make it harder to get insurance. Fighting
the rejection could take months. You might easily have been
rejected for some seemingly minor thing (my child was rejected
for having had three ear infections as a two-year-old). You
might have been rejected for errors in your medical records (as
I was). Getting all this straightened out can take a long time.
Meanwhile, you'll lose your Cobra option, and then you'll
basically be uninsurable. Having been through all this myself, I
suggest biting the bullet and some how paying the Cobra. When
the Cobra ends, even if you do have health problems (like ear
infections -- ear infections! What two-year-old doesn't have ear
infections?) you will be eligible for ''guaranteed issue''
insurance, which is available to anyone who has had their Cobra
options run out, even if that person has health issues.
Again, a broker is strongly recommended. A broker can help you
through all this, and will cost you nothing extra at all.
Good Luck! --Been There
My experience is that they routinely reject people for what
seems like no reason. I would get yourself a broker and work
through them- they can give you lots of advice and advocate for
you with the insurance companies. We use Myers Stevens 415-543-
4040 and I have been very happy with them. Good luck!
We went through this exact same thing with Blue Cross PPO indiv.
plan when my husband switched jobs to a start up that had no
benifits. We wanted to get pregnant and had to wait *5 months* to
start trying until we were finally accepted b/c they won't take
''pre-existing conditions''. When we called they said we may get
regected because I have asthma and also take paxil a few days per
month for pms, and my husband might get regected because he once
told his doctor his back was a little stiff and back problems are
also pre existing!
What we did was keep calling blue cross. They even told us if we
got regected once to re-apply and let them requisition all our
doctors for our medical records. They ended up accepting us the
first time, but not until they called every one of our docs for
the past 5 years (including my 3 yr old son's) and pouring over
It sounds to me like maybe the online process didn't get the
close attention you needed. I would advise calling a
representative and asking them to look at your case and pinpoint
the problems, and find out exactly who was regected, you or your
We all had to apply separately (not as a family), on our own
individual plans for them to take us. You should ask them if they
would encourage you to re-apply. If they don't sound encouraging,
call back another time and get a different representative. We
almost didn't apply b/c one person discouraged us. Then when we
called back the next day we got someone better who helped us
follow our case all the way through. If this happens, call Blue
Cross back every week or so, through each step of the process
until the end to make sure your case is getting the proper
attention. We found if we call back and politely enquire (e.g.
have they requested records from our docs yet, did they get the
forms we sent, is there anything we can do to help the process
etc), emphasizing how worried we were and how important this was
to us, that it went a long way to get them to pay attention to
You might also try other health insurances.It is a bit more
difficult once you have been rejected by one, but I've heard if
you are honest and keep trying, you can get accepted, it just may
take a long time. Fortis takes almost anyone, but they don't
have maternity coverage in California. so I guess they take
mostly men ;-)
I'm sorry this happened to you, I know how frustrating it is. We
were dumbfounded by how hard the process was!
Now we are pregnant and happily insured! I hope it works out for
Been there for five months of awful waiting!
You are not alone in your experience with Blue Cross. Just
hearing about your experience makes my blood pressure go up!
Having been through almost the exact experience as you, I can
recommend what we did. We got advice and help from a really
smart broker, after being sucked dry by high COBRA bills and a
long tale of horrors with Blue Cross. With our broker's help we
swtiched to the only non-profit insurer left, Blue Shield. Blue
Shield is far from perfect but much better than the others. We
prefer a PPO with a high copay and high deductible which is
offset by a lower premium. We've been self employed for 17
years, with two children, and this type of policy has served us
well. The broker I swear by is Bob Copeland, Copeland Insurance
of Larkspur, CA. 415-461-6137. Good luck to you. If anyone can
help you , Bob can.
Burned by Blue Cross, but only once!
We went through the same problems you had, but were rejected by
Blue Shield. We went through the process of appealing the
decision, to no avail. (They don't make it easy.) Finally, we
applied to HealthNet, and were approved - we did let them know
about our rejection from BS. Instead of paying Cobra's high
rates, you can go to a broker and get a temporary insurance
policy for your family (only covers catastrophic injury) at a
very reasonable rate per month. Good luck!
We too were rejected by Blue Cross -- as well as just about
everyone else -- right after my husband was laid off. We're a
young healthy family, but my husband takes an expensive
prescription drug and that was enough to keep us from getting
insurance. I posted to this list and someone suggested health
insurance broker Tony Uccelli who was really a godsend. He was
incredibly helpful in finding an affordable solution for us, and
we are all now happily insured (although not all by the same
insurer). I can't seem to locate his number at the moment, but
he's in the 650 area code. Good luck!
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