Tom Schrette and Alan Cash

Tom Schrette and Alan Cash

J.L. Sousa

Dear Tom and Alan:Following your recommendation, I enrolled in Blue Shield individual beginning Jan. 1 of this year.

Since you told me that this is the only surviving PPO in our area, I didn’t see that I had much choice. I did want to pick my own doctor which is what a PPO is supposed to let you do.

Two problems:

1. My welcome to Blue Shield letter named a doctor as my primary care physician. Never heard of him.

2. I went to a local medical group and they told me that even though they are contracted with Blue Shield, they’re not contracted with the new Blue Shield IFP.

What’s going on?

Stuck

Tom: There are two types of contracts that medical providers can sign with Blue Shield. One is for employee groups and the other is for Individual/Family Plans (IFP).

On the member’s ID card for group, it says simply PPO (Preferred Provider Organization).

On our reader’s Blue Shield card, it will say “Network PPO: Exclusive.”

Blue Shield tells me that this is not an Exclusive Provider Organization (EPO), just a confusing way to describe the network of providers. Actually, they didn’t say “confusing”…I just threw that in.

Al: This reminds me of when the Affordable Care Act (ACA, Obamacare) first kicked in. Anthem Blue Cross had offered the Prudent Buyer Network for just about everyone in California.

I was really happy to sign up people on a guaranteed basis, no pre-existing conditions to worry about and some even got a subsidy!

It turned out that Blue Cross had come up with a different network that pretty much had zero doctors in Napa.

Tom: OK, now back to Blue Shield in the here and now.

The company tells me they are not limiting the number of providers in any area, and would like to have a full complement of general practitioners, internists, specialists, labs, hospitals and other providers everywhere.

I called the contracting department at Blue Shield and was told they are willing to sign any provider that wants to contract with them. The provider services number is 800-258-3091, or online at BlueShieldCa.com.

For our reader’s local medical group, they seem to be encouraging “Stuck” to nag them into getting contracted.

There does seem to be some confusion about the word “Exclusive.”

The term does not mean Covered California.

The Network PPO: Exclusive is the only network available in 2018 for the Blue Shield IFP product, whether through Covered California or directly through Blue Shield.

Given the lack of communication from the company, our reader’s puzzlement is understandable.

Al: Also, even with a limited network at this point, Blue Shield is still the only PPO left standing. Health Net is an EPO and Kaiser is an HMO.

We do encourage our customers to contact their doctors to sign up so they can continue as patients.

Submit questions to schrette@gmail.com or alancash@gmail.com.

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