Blue Cross Blue Shield of Arizona (BCBSAZ) provides large, self insured groups access to the BCBSAZ provider network……………..But how do they keep their PPO payment methodologies secret from the TPAs and more importantly, plan sponsors who pay the bills?
By Molly Mulebriar
Like a few other BCBS plans, BCBSAZ rents their PPO network to a select group of independent third party administrators. But what does BCBSAZ do to keep their proprietary PPO “discounts” secret? As you know purveyors of PPO networks jealously guard their reimbursement schedules. Even plan sponsors whose medical care spend is dependent upon PPO pricing schedules are not allowed to see them. Giving a blank check to a third party intermediary has a tendency to cost more according to my Uncle Hermann.
So what’s the deal in Arizona? Do TPAs with access to the BCBS network have the keys to the Golden Kingdom of Proprietary BCBS PPO reimbursement strategies?
The answer can be found below:
Facility / Institutional Claims – electronic and paper – submit to BCBSAZ All claims for contracted facilities within the state of Arizona must be submitted to BCBSAZ. Do not submit institutional claims to TPAs. TPAs have been instructed to return these claims to providers for submission to BCBSAZ.
Yes, that’s right. All hospital / facility claims must be submitted directly to BCBS in order for Mystery Calculations are performed behind the curtain and payment amounts identified.
What functions does the independent TPA perform? A partial answer is found below:
Online access for membership status, schedule of benefits and claim status may be available through the TPA. Websites are included in this listing. BCBSAZ network providers may need to register at the TPAs’ web sites in order to obtain online access. Any questions regarding the TPAs’ online capabilities should be directed to the TPAs.
What TPAs are currently accessing the BCBSAZ PPO network? Who are the plan sponsors who are benefiting? See below:
www.azblue.com/~/media/19F9DE7842E2400F97BD97FF0530B7AF
