Many people likely fall victim to these very practices – and never know it!

This is a true story about a health insurance nightmare – one that has been going on for at least seven years.

Put yourself in the shoes of the person who wrote the email below*.  What would you do if you were this individual?  What needs to be done to prevent these kinds of problems?  Read this email, and then let me know what you think.

“Dear Blue Shield representative,

My most recent plan started on January 1st of 2016.  On March 6, 2016, I not only satisfied my deductible requirement of $4,500, but actually exceeded it by $175.31However, Blue Shield (hereafter ‘BS’) claimed until September 7, 2016 that my deductible was not satisfied.  

On March 30, 2016, I also met my annual out-of-pocket maximum of $6,500, and actually exceeded it by $101.47.  Despite this, the BS website reflected that I had only paid $1,256 of the $6,500 limitation.  Further, BS required my CVS Pharmacy to continue to collect funds for each prescription I had to fill until September 11, 2016. 

You yourself told me that the BS system has not been calculating and accruing deductibles properly for some small group plans for at least 3 years. 

I have spent more than 55 hours in 2016 alone trying to get BS to stop requiring CVS to collect payments from me for deductibles and co-pays in months after I had met those requirements.  In April, May, June, and August of 2016, I provided BS with proof of this using information from my HSA debit card statements and from CVS statements, and I did so before resorting to filing a grievance.

Then on September 26, 2016, I received several checks.  However, I have no idea what each check was for because none of them identified any claim number against which it could be matched.  Cooincidentially, for the last two years, I have received refund checks, all with no explanations and, all dated with the same day and month as those received the year before.

Surely, you must sense my frustration over having had to go through this with BS.  Worse still, this is the exact same dance I have had to go through for each of the last 7 years, and all because BS cannot or will not correctly accrue plan deductibles. 

Please advise.“


How extensive this problem is, we do not know.  But, based on the evidence provided by this individual, we know this problem has existed for at least 7 years, across a variety of plans, and that Blue Shield has known about the problem for some time.

When BLUE SHIELD advises a plan participant that they have met their deductible and co-payment requirement for the plan period, that person is most likely happy or at least relieved.  However, that individual may not realize that it is statistically unlikely that they would have met their deductible and co-pay requirements to the exact penny.

Bottomline it appears Blue Shield is either unable or unwilling to properly calculate, accrue, report and refund deductible and co-pay overpayments when appropriate.

We suspect this problem is a symptom of a greater problem, i.e., intentionally being slow to accrue or to accurately accrue deductible and co-payments, believing that most plan participants will never realize that they have paid more than they should have. 

Remember, this is a true story.  At the beginning of this blog, I asked you to put yourself in the shoes of the person who has lived with this nightmare. Now I ask you:

  • How do you know you or a loved one are not in the very same situation but don’t know it?
  • How much does Blue Shield benefit from float simply by not repaying money promptly?
  • What happens to any money that Blue Shield does not refund?

And one more question: What is Blue Shield’s incentive to fix – or not fix – the problem? 

Please, let me know what you think.  Thank you.

* Redacted to remover personal and complicated detail.

By Susan Wayo
Principal
The Gendreau Group