Time line of Blue Shield of California Problems
Feb 20, I exchanged emails and calls with Tony Giardino at Blue Shield.
Tony Giardino
Agent ID M866 DS
License # 0D07301
Blue Shield of California
PO BOX 629015
El Dorado Hills, Ca 95762-9015
Phone 818-228-6284
Fax (800) 780-7540
Membership (to check status) (888) 256-3650
Tony Giardino
CA License #0D07301
Blue Shield of California
Individual & Family Plans
Direct Sales
P.O. Box 629015
El Dorado Hills, CA 95762-9015
Anthony.Giardino@blueshieldca.com
Phone: (800) 660-3007 ext. 228-6284
Phone: (818) 228-6284
Membership (to check status) (888) 256-3650
I informed him that I went to Blue Shield directly, because I knew that I did not qualify for any financial
assistance. I chose their “Preferred PPO Gold Plan”. I called all of my doctors and hospitals to make
certain that they were on Blue Shield’s PPO network. They all said “yes”. One office said, “…not if it was
set up through Covered CA”, and I said that it was not – that I went directly through Blue Shield.
TYPE
NAME
PHONE
UROLOGIST
SZE-CHING LEE
PODIATRIST
RICHARD RUPP
818
245-0143
818
247-0523
FAMILY
PRACTICE
818
246-3306
SPORTS
MEDICINE, PT
SHALOM MEDICAL
DAVID HAN,
ESTHER YOON
DONNIE
RICHARDSON
ORTHOPEDIC
SURGEON
BEHROOZ
BROUKHIM, MD
818
508-6188
818
508-6188
IN NETWORK OR
NOT
YES, if it's a PPO
not if done
through Covered
Ca
YES, if it's a PPO
Yes.
Billing through
Dr. Broughim
YES, if it's a PPO
CARDIOLOGIST
AUGUSTO SILVA
HOSPITAL
PROV. ST JOSEPH
MED CTR
tax id # 95-1675600
PROV. ST JOSEPH
HEALTH CTR
HEALTH CTR
818
846-2546
818
843-5111
YES, if it's a PPO
YES, if it's a PPO
501 S. Buena Vista St.
Burbank, CA 91505
818
953-4451
Same as Med Ctr ?
3413 W. Pacific Ave
Burbank, CA 91505
201 S. Buena Vista
Street, Suite 125
Burbank, CA 91505
18411 Clark St, Suite
107
Tarzana, CA 91356
1150 Indian Hills Rd,
Suite 230
Mission Hills, CA
91345
DIAGNOSTC CTR
PRO. ST. JOSEPH
DIAGNOSTC CTR
818
848-4988
Same as Med Ctr ?
HOSPITAL
PROV.
TARZANA MED CTR
818
776-9526
YES, if it's a PPO
HOSPITAL
PROV. HOLY CROSS
MED CTR
818
838-9558
YES, if it's a PPO
818
981-7111
818
409-8000
310
825-9111
818
907-7546
818
238-2350
Did not call
HOSPITAL
SHERMAN
OAKS HOSPITAL
HOSPITAL
GLENDALE
ADVENTIST
HOSPITAL
UCLA,
RONALD REAGAN
DERMATOLOGIST MID-VALLEY
DERMATOLOGY
DERMATOLOGIST RACHEL D. BAK
Dermatologist
YES, if it's a PPO
YES, if it's a PPO
YES, if it's a PPO
YES, if it's a PPO
I signed up for the “Preferred PPO Gold Plan” at a monthly premium of $789.44, effective April 1, 2014.
May 12
I arrived for an appointment with my Podiatrist to follow up on a surgery he had done on
me two years prior, and I was informed that he was not accepting Covered CA patients. I strongly stated
that I was NOT in a Covered CA plan – that mine was a Blue Shield Preferred PPO Gold Plan. They said
that the prefix on my Blue Shield member number (XEK) and group number X0001000 defined me as
Covered CA.
SO MUCH FOR CONTINUITY OF CARE !
I called Blue Shield Customer Service, and someone there sent me a letter stating that I was a Blue
Shield PPO Plan and NOT Covered CA.
I had just lost one provider. What would be next ?
May 12
I emailed Blue Shield sales rep :
Tony,
I just found out today that I was placed in the wrong plan. I went to the Blue Shield website directly -not Covered California -- with the express purpose of signing up for the PPO Gold Plan as shown on the
Blue Shield website.
Before I signed up I called all of my doctors and hospitals to make sure that they were contracted under
the Blue Shield PPO plan. They all said "Yes", but more than a couple of my doctors said that they were
contracted on the PPO plan but not if that PPO was set up through Covered California.
At no time did you mention the phrase "Covered California", which would have sent up a big red flag,
Today I was told by a Blue Shield Customer Service rep that the three letters at the head of my member
number (XEK900940389) indicate a Blue Shield plan that is NOT Covered California. She further said
that the prefix XED is used for all Covered CA plans. But today THREE offices told me that she is wrong -that I have a Covered CA plan, and two of them are not contracted for it. It's still called a PPO, but it's
apparently an EPO in disguise.
I now have no idea what doctors or hospitals are contracted under my plan. I am getting opposite
stories, and I need to know ASAP what is going on in order to obtain covered medical care under a REAL
PPO plan.
If you need to escalate this matter, please do so immediately.
Thanks,
Richard Morrone
(818) 522-1143 M-F 8:00-5:00
May 13 from Tony
Hello,
The plan you applied for is a direct plan with Blue Shield PPO, keep in mind it uses the same network as
if you purchased a plan through Covered California. The network is the same if you buy direct or go
through Covered California. It is true that there are 2 different codes that are used referring to XEK or
XED, but both have the same network of Dr’s, the difference is that if you go through Covered California
you most likely are getting premium assistance and that is the reason people are applying through
Covered California. The Doctors and hospitals you called may have said they contracted with Blue Shield
, but what they did not specifically say that is was not for individual plans but group plans with Blue
Shield of California, so that is what you are probably running into.
If you want to check to see if your physician or hospital is contacted for the individual plans you can go
to www.blueshieldca.com and click explore and click health plans and click find a provider and click
select a plan and set it to the 2014 Individual and family plans for PPO. Then select the sub plan like the
Preferred gold plan, then you can look under Doctors and hit advanced search and type in the Dr’s name
or look under hospital and do a zip code search if you want to see the hospitals that contract in your
area. Hope that helps you understand!
May 13
I emailed the sales rep.
Tony,
You and I established at the start that I didn't qualify for government assistance, so Covered CA was not
a consideration.
What Blue Shield PPO Gold plan is there that is NOT using the same network as Covered CA and that
my doctors ARE servicing? They are certainly contracting with Blue Shield as some sort of in-network
PPO provider.
As to your search engine, I have already been there, and it returns doctors that are well out of my
specified zip code and gives me all sorts of different types of doctors. I put GP's and get Chiropractors.
May 13
Letter from Blue Shield Customer Service in response to inquiry number 141330001696
stated that, “Our records indicate that you are currently enrolled in IFP OFF EXCHANGE PREFERRED
PPO alpha prefix XEK which is not a Covered California”.
May 17 – a weekend.
I experienced shortness of breath and some chest discomfort.
May 19
I went to my cardiologist, Dr. Augusto Silva, for what had been scheduled as a routine visit,
and he told me that I was sitting on a time bomb for a stroke! My heart was in atrial fibrillation on top
of my mitral valve prolapse problem. He ordered blood tests across the street at Providence St. Joseph
Medical Center and put me on a blood thinner and a drug to slow down my heart and lower my blood
pressure. He scheduled me for a transesophageal echocardiogram and a cardioversion for Friday May
23 once he was sure of the clotting levels with a Thursday protime blood test.
I went to Admitting (818) 847-3404) at Providence Saint Joseph Med. Ctr. I warned them about the
problems that I was discovering with my insurance network and said that I wanted to be sure that the
hospital was truly in my Blue Shield network. Adrienne (or Adriane) assured me that Financial would
confirm network coverage and let me know before the Friday May 23 procedures if there was a
problem. That call never came, so I figured I was in the clear. After all, St. Joseph had told me in mid
February that they were in-network, and I had also saved the following May 13 search results from Blue
Shield confirming that St. Joseph was in-network :



HOSPITALS (Information updated on 05/13/2014)
Los Angeles Providence St Joseph Med Ctr 501 S Buena Vista St Burbank, CA 91505 (818) 843-5111
Distance: 3.87 miles Inpatient: $$$ Outpatient: $$$
Mission Community Hospital 14850 Roscoe Blvd Panorama City, CA 91402 (818) 787-2222 Distance:
5.72 miles
Valley Presbyterian Hospital 15107 Vanowen St Van Nuys, CA 91405 (818) 782-6600 Distance: 4.57
miles Inpatient: $ Outpatient: $
I had blood work done, including protime for checking my clotting factor. I had another protime on the
22nd, the day before the procedures.
May 22
Two calls came to the home from (818) 843-5111, at 11:45 AM and 5:37 PM. Someone
named Pauline called for medical prescreening. She called my home during the workday and not my cell
phone, which I had provided to Admitting. A number was left – (818) 847-3510, option 2 to speak to
Pauline. I got home after 6:00, and could not reach her. A Sonya in Financial has notes stating that she
called the home at 5:41, but she left no actual message, no word of financial problems – just her name
and number. Her 5:41 call might be the second call (which came to my home at 5:37), because no other
St. Joseph number was recorded on my incoming call record on the evening of May 22.
May 23
The two procedures were done. Something that was said that day caused me to make
further inquiries on May 27 about in-network status.
May 27
I called Blue Shield customer service and was told that St. Joseph was not contracting with
Covered CA plans, and that meant ME. I also reported the emergency procedures performed on May 23
(there was a 3-day weekend that had intervened).
I got customer service to initiate an appeal (ref. number 141470011703) to get me into a better network
than the Covered CA so that I would not lose my doctors and hospitals. Blue Shield promised a 30-day
response period; I received a letter to that effect, signed by Wilver O.
I emailed the Blue Shield sales rep :
Anthony,
What do you and I have to do to get me onto the network that I thought I thought I was signing up for
when I first came to you. A higher premium... what ?
The fact that Blue Shield moved me into a Covered CA network without telling me that this would
happen constitutes a "bait-and-switch", and I just got clobbered with the news that a procedure I had
done last Friday at my local hospital, which is not handling this Covered CA network, is going to cost me
a huge amount.
I want a solution ASAP, before anything else happens in my life and health.
This is, I assume, above your pay grade to address, but please call me about how Blue Shield and I can
solve this mess.
Thanks,
Richard Morrone
(818) 522-1143 M-F 8:00-5:00 day
Home after 6:30 PM (818) 761-8156
[Tony called me back and said that all individuals and families are automatically placed in the Covered
CA network. Only group plans avoid this at this time. I responded that if that had been stated when I
was applying that he and I would not be talking,, because I never would have signed up with Blue Shield
under such a condition.]
May 28
I had to call my cardiologist and tell them to cancel the angiogram scheduled for May 30.
I had to get a handle on this insurance situation. I was scared to run up a bunch of huge bills, and the
cardioversion had me reasonably stabilized for the time being. My cardiologist was, nevertheless, very
concerned about his ability to adequately care for me. I could go back into A-fib at any time.
May 29
I found a 3:13 PM message (once again on my home phone) from Cecilia in Financial at Saint
Joseph at (818) 847-3418. However, she did leave a message that St. Joseph was not contracted with
Covered CA and that I would be responsible for a very large bill, because Blue Shield would pay only
$500 of a roughly $5,500 bill for a heart angiogram. THAT WAS THE SORT OF CALL THAT I SHOULD HAVE
RECEIVED ON MAY 22 BEFORE THE TWO PROCEDURES WERE DONE ON THE 23rd. The reason that Cecilia
had called was that the system showed that the angiogram was still scheduled.
May 30
I spoke to Cecilia and thanked her for the message about the insurance problem (even if it
was left on my home phone during the work day). She strongly suggested that I call Blue Shield again
and push for an immediate answer on the appeal. I called Blue Shield and asked Customer Service to
find me a cardiologist on the network with privileges at either Valley Presbyterian or Glendale Adventist.
Nicky also gave me the number of Wilver O. who was working on the appeal (818) 228-2697. Voicemail
stated that his FAX is (916) 350-6683. Nicky promised to (but did not) get back to me with the name of
a cardiologist in the network with privileges at Valley Presbyterian. Someone at Blue Shield called my
home from (916) 910-0768 at 6:01 PM but did not leave a message.
I got a protime blood test at Glendale Adventist Lab at 1560 Chevy Chase Dr. in Glendale.
May 31
I was home to receive another call from (916) 910-0768. It turned out to be a Blue Shield
customer satisfaction survey. I gave my opinion in no uncertain terms.
Someone at Blue Shield sent an email at 7:40 AM which stated :
The key to accessing health care is finding the right doctor for you. If you need to find a primary care
doctor for your general medical needs, or even a specialist, we have a great online resource to help you
locate doctors in your area and network. Just follow these four simple steps:
1. Register and log in as a member at blueshieldca.com.
2. Click the Find a Provider button on the top of the page.
3. Select the Advanced Search link under "Doctors."
4. Fill in the search fields and select Find Now.
And if you have a medical concern and aren't sure what to do, you can call NurseHelp 24/7SM,
at (877) 304-0504, for immediate health advice from a registered nurse at any time.”
You might ask why I wasn’t already using the search engine. The fact was that I was, even before I
signed up. The results were unreliable. A search for a cardiologist within a 5-mile radius returned a
total of six. A different search with a radius of 5 miles returned results as far away as 15 miles.
On another occasion I did a search for hospitals close by, and it showed Providence Saint Joseph in the
results. I saved that PDF file. St. Joseph, of course, is telling me that they are not in the network. The
Blue Shield Search says one thing while St. Joseph and Blue Shield Customer Service say another.
Please note below the misleading search criteria. My logon produces a plan selection of “Preferred
PPO”. Looks correct – right? Wrong. I had to call Customer Service several times to find someone who
knew that the correct name for my plan is not what the Search engine shows me when I log on, despite
its showing my name and address. It should default to plan my name. Instead I must repeatedly use the
dropdown and change the plan selection to “2014 Individual and Family PPO Plans (including Covered
California)” (the plan that they secretly put me into) to do a search for providers.
How is a person supposed to navigate such treacherous waters ?
June 2
I spoke to “Claims”, and we submitted a “Continuity of Care” petition (Ref. # 141530015819).
She asked me many questions and took down the names of Providence St. Joseph Med Ctr and Dr. Silva
– the goal being to get them placed in my Blue Shield network for the management of my condition.
About three hours later at 7:04 PM Wilver O. called to tell me that he had received the “Continuity of
Care” petition. After he listened to my whole, long story he said he would be processing the petition
quickly. He told me about the confusion out there with doctors’ offices and hospitals not understanding
that they also needed to contract for the PPO that I am currently in – that they should not just assume
that handling the previous PPO’s meant that they would automatically be contracted for the new ones.
We agreed that there were two things in the works. One was the “Continuity of Care” petition. He said
that an answer could come within 5-7 business days. The other was the appeal initiated on May 27 to
somehow get me into a better network (like I thought I was signing up for in February) – one where I did
not lose all of my providers. He estimated a 30-day response time on that one. He said that there were
other plans available that would have given me access to a wider/better network. I was shocked at
hearing this and asked why that was the first time I was hearing about it.
I noticed that he was a bit quiet when I said that I had received a letter from Customer Service stating
that I was a Blue Shield IFP Off Exchange Preferred PPO and “NOT covered CA”.
June 3
I spoke with my cardiologist Dr. Silva about all of the delays in my care. He was surprised to
learn that he was not in my PPO network after his staff had assured me that he was. He was worried
about getting me an angiogram in a timely manner, and especially before his leaving town for three
weeks starting June 10.
With Dr. Silva out of town on vacation, and with an associate who is not in the network, he had no way
of monitoring my protime lab results to stay on top of my blood clotting factor and Coumadin dosage.
I gave Dr. Silva Wilver’s name and number so that he could make a stronger case for a quick resolution
to this matter. Dr. Silva could only leave a message on Wilver’s voicemail. That’s as far as that went.
Wilver did not return the call.
After lunch I got a call from Chris at Dr. Heather Shenkman’s office [(818) 848-0023]. She and Dr. Silva
had spoken, and it was agreed that she would cover for Dr. Silva and do my angiogram on June 12 at
Valley Presbyterian Hospital. The plan was that whatever amount Blue Shield would pay, I was to simply
hand the check over to Lakeside Community Healthcare, and that Lakeside would accept that as
payment in full and not send it out for collection of the balance.
June 4
I tried to search the Blue Shield website for doctors and hospitals and gave up. I spoke to
Customer Service who ran searches for me and emailed the results as PDF’s. On the list was Keck
Hospital of USC. I tried to get through to Cardiothoracic Department, but I was disconnected twice.
June 5
I called Keck’s Cardiothoracic Department again at 8:15 AM and spoke to Ashley. She took my
info, and I emailed her a photo of my insurance card. She called back within the hour and said that Keck
was contracted to cover me for clinical (with a $50 copay) as well as surgical at 80% with maximum
annual out-of-pocket of $6,350. [ Note, maximum out-of-network annual out-of pocket limit = $9,350 ]
June 6
I got a protime blood test at Quest Labs on Riverside Dr. in North Hollywood in the hope that
my cardiologist could read it before leaving on vacation on Tuesday June 10. He did.
June 8
Filled out CA Dept. of Managed Healthcare complaint form regarding Blue Shield’s business
practices. (800) 400-0815 M-F 8:00 AM – 6:00 PM Help Line: (888) 466-2219 www.dmhc.ca.gov.
June 9
I called Blue Shield and got a recording that announced that my plan’s total combined
maximum annual out-of-pocket limit for allowed services is $9,350. This means that the annual out-ofpocket limits “cross apply” for in-network and out-of-network services. This means that in-network
expenses count toward the out-of-network limits, and vice versa.” So my total combined annual outof-pocket limit for allowed services is $9,350.
June 11
I mailed the Fraud Complaint to the Department of Managed Health Care in Sacramento
from the Studio City Post Office (certified/signed receipt).
I called Blue Shield Customer Service and was told that Providence St. Joseph Med. Ctr. was IN my
network. I explained that I had pieced together that my Preferred PPO (Gold) plan is an IFP (Individual
and Family Plan), off-exchange plan and not in a Covered CA plan but that it is in a “mirrored” Covered
CA network of providers. I was switched to Claims Department.
The Claims Department said that Providence St. Joseph Med. Ctr. was NOT in my network. They said
that they would mail me a letter that thoroughly explains what is going on with my plan and network.
That letter never came.
Claims told me that the procedures on May 23 were billed as mere outpatient procedures and not
“emergency”. I explained that if I had walked into the ER when this A-fib started and they had shocked
my heart, I could easily have had a stroke. My emergency treatment had to come in two stages. First I
had to go on a blood thinner for 3 days and then get the emergency cardioversion shock procedure.
That did not make it any less of an emergency procedure.
Claims told me to have the providers resubmit the claims with emergency coding. I called St. Joseph
Med. Ctr. They said that the doctors’ dictations are interpreted by transcribers as emergency or not,
and that claims are submitted accordingly. With Dr. Silva on vacation from June 10 to June 23 that
delayed the process of correcting the dictation.
June 12
I had my cardiac angiogram done by Dr. Heather Shenkman at Valley Presbyterian Hospital.
A protime test was done just prior. All went well, and Dr. Shenkman said she would send my records,
the transesophageal echocardiogram and cardiac angiogram to Keck Hospital for my consultation.
June 13
I called Wilver O. and left a message asking for an answer to the Continuity of Care request.
He had estimated a quick answer by June 2nd (5-7 business days). Wilver did not return the call.
June 16
I called Dr. Shenkman’s office to make sure that my records were sent to Keck. They had
not when I called near the end of the day.
June 17
I mailed the complaint form for Covered CA from the Studio City Post Office To :
STATE OF CALIFORNIA
DEPARTMENT OF INSURANCE
CONSUMER SERVICES AND MARKET CONDUCT BRANCH
CONSUMER SERVICES DIVISION
300 SOUTH SPRING STREET, SOUTH TOWER
LOS ANGELES, CA 90013
I also went online and found the USPS record of the delivery of the complaint I had sent to the CA
Department of Managed Health Care on June 11. It was delivered on June 13.
Chris at Dr. Shenkman’s office was dragging his feet about sending my records to Keck. By Tuesday
afternoon June 17 Chris still had not done anything about my material. I emailed Keck, and Ashley
replied with instructions. I called Chris and said that I would forward the email to him, which I did.
June 18
I called Chris again to insist that he at least get the CD’s mailed out. He told me that I would
have to obtain the two CD’s from the respective hospitals. He would FAX my chart records. I already
had a CD copy of my angiogram from Valley Presbyterian, which they had made on the day of the
procedure. I called Saint Joseph Medical Records and arranged to pick up a copy of the echocardiogram.
June 19
I picked up the CD of the echocardiogram at St Joseph Med. Ctr. I sent it and the cardiac
angiogram CD to Ashley Valentino at Keck/USC Cardio Thoracic Institute via USPS Priority Mail.
I got a protime blood test at Quest Clinical Labs. Dr. Shenkman received the results.
June 20
Julisa called for Dr. Shenkman to have me modify my daily 5mg dose of warfarin (blood
thinner) to 7.5 mg and to get another protime test on June 26.
The USPS tracking website showed that the two CD’s were delivered to Keck on Friday June 20.
June 23
I called Keck to see if they had received the material. Ashley had the FAX’s of my records.
She told me that a “Sherry” would be calling me sometime around 5:00-6:00 PM to discuss matters with
me. Sherry never called.
I searched Blue Shield for Urgent Care facilities, pulmonary specialists and imaging facilities. On May 12
my GP Dr. Yoon had ordered a CT with contrast to explore a 9-month-old persistent cough and lung pain
when inhaling – possible next step, a pulmonary specialist. I had to find a different imaging facility,
because the one she chose was not in-network.
Blue Shield Customer Service confirmed the in-network status of San Fernando Valley Interventional
Radiology and Imaging at 16311 Ventura Blvd. # 120, Encino CA 91436 (tax ID 562631760) for my CT
scan. Dr. Yoon’s call to them ordering the CT is what Blue Shield calls prior authorization, but the person
at Customer Service also gave me a number to call for prior authorizations (888) 642-2583. I got the CT
that afternoon.
I also asked Blue Shield Customer Service for the status of my two appeals :
 As to the May 27 appeal 141470011703, she found that it had been turned over to someone
named Rosie V. at 818 228-6199.
 As to the June 2 appeal 141530015819, she called medical management to check the status.
She reported that one provider was slow in getting back to them with additional material, but
once the material was complete an answer would come in 5-7 business days. Why didn’t Wilver
O. tell me that in my two requests for an update?
Three providers had been contacted – Dr. Yoon, Dr. Silva and Saint Joseph Med Ctr. I did not know
which was slow in returning the additional material.
June 25
I called Rosie V. at Blue Shield Grievance for a response to my May 27 appeal. I had to leave
a voicemail. When she returned the call at lunchtime my cell was getting poor reception, and I could not
answer in time. I recognized the number and immediately called back. I got the voicemail again and left
a message. I don’t know when she called back, but when I got home I noticed a message on my cell.
She said that she had mailed the appeal response on June 21 (that was a Saturday). I called back and
left another voicemail and said that I had been to my P.O. box June 25, and there was no response to
the appeal. I further said that I hoped that she had used my mailing address (the P.O. box) and NOT my
home address.
I emailed Ashley at Keck asking for faster action on my case, since Sherry had not called me on Monday
evening or Tuesday evening as I was told by Ashley that she would. I wrote that I was getting more
short of breath and that I was getting weaker by the day. She emailed me back to apologize and wrote
that she would cc my email to Sherry. Sherry called me at 4:15 PM and said it was useless to leave a
message on her voicemail and that she would have to call me. She said that the surgeon Dr. Starnes was
on vacation until July 16. I said I was willing to go with Dr. Baker instead. She said that we had only the
next day (June 26) to gather any remaining records, because she was leaving on vacation on Friday June
27 and that she would call me at home that evening June 25 to work me up and let me know what
additional she might need. For the third time, she did not call. For the third time I spent my evening
glued to the phone and waiting.
June 26
I emailed Ashley at Keck again and asked for her help once again. I wanted to talk to anyone
who might be covering for Sherry during her absence. At 7:00 PM I got a call from Sherry. She had
someone named Alexis Brazda on 3-way. Alexis was to call me back in a few minutes for the work-up.
She called back at 8:00 PM. We planned the next day’s possible gathering of needed reports and tests.
I got a protime blood test at Quest Diagnostics in West Hills.
At 1:30 PM I received a callback from Rosie V. at Blue Shield. She said that she did use my P.O. box to
mail the response to the May 27 appeal and confirmed that it was mailed on Saturday June 21. I said
that it had not arrived as of Wednesday June 25. We talked at length and when I mentioned the Blue
Shield provider search producing a PDF showing Providence Saint Joseph as in-network, she said that
this had not been brought to her attention and that she would generate a new appeal to assign innetwork status to Saint Joseph for the tests and procedures done at Saint Joseph on May 19, 22, and 23.
She gave me her email address, and I sent her the PDF at 3:16 PM and included some of my story as
well.
June 27
I called Alexis for the final pickup list and had to leave a message twice. I called again, and
she said that Bob was not in that day, and she needed to ask someone else. She needed a signed form
for Authorization & Consent, Disclosure & Transfer of Medical Records. She said she would send a blank
to me right away. I waited around the house until 2:30. She still had not sent the form. I called to get
upset with her and Keck. After all, she had said that she would get answers for the pickup list and that I
would be on the road gathering the items on the pickup list. With Bob’s absence she was going to ask
someone else, and she still had not done so. I told her I had just sent her a signed form, having found it
in the “New Patient” packet. She called back at 3:22 having arranged for FAX;s of remaining reports and
for my picking up a CD of the CT at SFV Interventional Radiology and Imaging on Monday PM. She
confirmed my 7:30 appointment with Dr. Craig Baker on Tuesday AM July 1st. Alexis confirmed that the
entire service would be in-network, according to Blue Shield.
I spoke to Cindy at Lakeside, and she gave me results of the protime. The INR was 2.8, and the new
dosage for warfarin was 7.5mg on Mon-Wed-Fri and alternating 5mg on Tu-Th-Sat-Sun. She told me to
get another protime in two weeks (July 11)
June 28
I checked the P.O. box. Mailed June 23, the Department of Insurance informed me
that they were turning my complaint over to the Department of Managed Health Care.
As to the June 21st mailing from Rosie V. at Blue Shield, it read that my appeal for a better network had
been turned down – that I would have to wait until open enrollment to make any changes. It was a
boilerplate response and addressed nothing of the misrepresentation on the part of Blue Shield and its
sales representative prior to my signing.
Neither my Application nor the Uniform Health Plan Benefits and Coverage Matrix (sent to me after
signing) mention anything about Covered CA networks being applied to my Preferred PPO plan. If Blue
Shield thinks this is a miniscule point, then it is out of touch with its customers – potential or otherwise.
Once again, if I had been informed that I would be in such a network, I would surely have signed up with
Kaiser Permanente instead.
June 29
I had a bad night – woke up many times with panic breathing from having stopped
breathing in my sleep or in twilight stages (in a sitting position). I can’t keep this up. The last 6
weeks have been really tough, but it’s getting worse, and I am afraid of this “trying” to sleep.
I will ask if I can stop the metoprolol. After all, this was the stuff that Dr. Silva was worried
could cause me to just plain die in my sleep. This was based on the holter monitor readout
from 4 years ago, showing how slow my heart rate went and how low my BP went in my sleep.
I know what my sleep apnea feels like, and this is different.
June 30
I called Lakeside to have Julisa to ask Dr. Silva (now back from vacation) to please redictate his notes for my May 19–23 procedures so that transcription would apply the needed
emergency codes. She gave me an email address to send the request to him, myself. I sent it
that day.
I went to Saint Joseph to talk to Financial, but the person there recommended that I drive to
the Regional Business Office in Torrance and hand the paperwork to a supervisor. I called the
Business Office (800) 750-7703 and was transferred to someone’s voicemail. I could not make
out the name. I called back and asked again. I was transferred to Vanessa Cota’s voicemail, on
which I left my name account and phone numbers.
July 1
Vanessa Cota called back form Saint Joseph Regional Business Office and gave me a
FAX number to send her my material. She said that Saint Joseph was in the midst of meetings
to determine how to handle the many errors and misinformation given by Saint Joseph and
insurance carriers. I basically said that everyone would have to wait for things to settle out
before I would be sending any money – that I was hoping for 3 or so possible approaches to a
correction.
I had my consultation with Dr. Craig Baker at Keck. He said he was comfortable with an
arthroscopic approach as well as attempting a repair of my mitral valve.
NOTE : It’s probably best at this point to build a separate timeline for Keck…
July 2
In my P.O. box I found another bill – this one from an anesthesiologist for the cardioversion at
Saint Joseph. I also found a letter from Rosie V. stating that the June 26 appeal was in the works and
that I could expect another 30-day response time.
July 3
I FAX’d the anesthesiologist statement to Vanessa Cota and separately emailed it to Rosie V. at
Blue Shield.
At 4:49 PM I received a call from (916) 403-6909. A “Janice” at the California Department of Managed
Health Care identified herself as an R.N. whose job it was to check on the medical status of people filing
complaints against insurance companies to determine if they needed urgent medical intervention.
I told her that I was reasonably stabilized though still at risk of stroke while awaiting surgery. She asked
for me to put in a nutshell what I want, and I stated that I wanted the following :
1. For Blue Shield to get me into a network commensurate with my nearly $800 monthly premium,
2. For Blue Shield to cover all medical expenses incurred in the month of May 2014, including the
cardiac angiogram performed on June 12 at Valley Presbyterian.
3. For Blue Shield to be forced to stop their fraudulent practices and therefore inform prospective
members of the type, quality and extent of the provider network so that prospective members
can make informed decisions.
Joyce told me that she would file the formal complaint against both Blue Shield and Covered CA
right then, before she left work for the day. She gave me the case # 741110 and the Help Line
number (888) 466-2219 with a hint to ask, “Who owns my case today?”.
July 5
I emailed Blue Shield asking for clarification on the bill/claim for the Valley Presbyterian cardiac
angiogram, Acct # V01008567032. On the date of service the provider ran my Visa card for an estimate
of $815.68. Blue Shield wrote a check # 11616998 to the provider for $738.00 on 6-27-2014. My
question was did this mean that the provider should not submit the $815.68 charge to Visa. DID I GET
A RESPONSE ? NO !
I left messages at two numbers at Valley Presbyterian about a second payment, and I asked for a credit
on my Visa card for $815.68. They got back to me and said that it had not yet arrived.
Summary :
This complaint is presented regardless of any possible future remedy by Blue Shield.
I am the victim of a bait-and-switch on the part of Blue Shield. Blue Shield knew full well what they were
doing, and without any discussion they took my so-called Preferred PPO Gold Plan with its $789.44
monthly premium and placed me in a very scaled-down Covered California-type network for people
paying much less. I had gone to them directly (not to Covered CA) to buy a better plan for myself and
later discovered that I never had any chance of purchasing such a plan for myself at the time of sign-up.
Later I found that it wouldn't have mattered if I had bought a bronze, silver, gold or platinum plan – the
provider network would have been the same. The only difference would have been in the various
combinations of premiums, co-pays and co-insurance features. Then, on June 2nd, I was told by Wilver
O. (in the Blue Shield Grievance and Appeals Department) that wider/better networks were actually
available. Why was I not presented with this information when I signed up?
Blue Shield misled me from the start. I told them that I was not interested in Covered CA. The form for
the application showed no description of a Covered CA plan. Blue Shield showed me a name and
description of their Preferred PPO Gold Plan, and I went to my medical providers for confirmation that
they were in-network. They ALL told me that they were, including Providence Saint Joseph Med Ctr.
On May 12 I showed up for an appointment with my podiatrist to follow up on a surgery from two years
ago and to discuss a possible reoccurrence of the problem. I was informed that he was not contracted
with my Blue Shield network. I started making calls to Blue Shield Customer Service to have them
confirm that I was not a Covered CA plan – that I was a straight Blue Shield PPO (Gold) plan. They sent a
letter that stated that my plan was not Covered CA. In other calls I was told that all individuals and
families were automatically placed in a “mirrored, off-exchange” Covered CA network. If I had been
informed of that at the time, I would never have signed up with Blue Shield.
On May 17, I went into atrial fibrillation after one of my “heartstrings” ruptured. The tendinous chords
connect the papillary muscles to the tricuspid valve and the mitral valve in the heart. That was in
addition to my existing mitral valve prolapse. I saw my cardiologist, Dr. Augusto Silva on Monday May
19. My acute episode had to be delicately stage-managed with 3 days on blood thinner BEFORE
performing a cardioversion on May 23 to return me to normal sinus rhythm. A trans-esophageal
echocardiogram was also performed. That’s how they found the ruptured heartstring. The fact that
this treatment took place over a span of 4 days did not make it any less of an emergency.
Before those hospital procedures, I warned Admitting at Providence Saint Joseph Med. Ctr. on May 19
that I was having problems with my insurance network, and they assured me that Financial would
confirm my in-network coverage before the procedure and notify me if there were any problems. They
did not, and it ran up a hefty bill. If I had been properly warned of a problem at that hospital I would
have cancelled the procedures and made arrangements at another facility that was in network. I was
compelled to cancel a May 30 angiogram because of these insurance problems. I finally got my
angiogram on June 12 at a network hospital. That’s 13 days after the initial/cancelled appointment.
That’s 3½ weeks after my visit with the cardiologist, when he told me that I was “sitting on a time bomb
for a stroke”.
It came as a surprise to my cardiologist when I informed him that he was not in the network either. Be it
at Blue Shield or the doctor’s offices or hospitals – at each of these one person says one thing, and
another person says something else. I have used the search engine on the Blue Shield website, but it
failed to base its searches on the specific plan that they placed me in. So I must use a dropdown and
choose a different plan name than the default name each time I log on. That is why I have a printout
that shows Providence St. Joseph Medical Center in-network. Now Saint Joseph does not show up as innetwork. WHY on earth would the search engine identify me so fully and yet skip over this vital piece of
information when I log on to do a search?
I did my due diligence BEFORE signing with Blue Shield, and I have done so since. It’s Blue Shield that
did not. It’s Saint Joseph Medical Center that did not (at least regarding their failure to alert me prior
to the May 23 procedures). When I discovered the problem on May 12, I pushed for clarification from
Blue Shield as well as from the providers. The assurances I received proved to be anything but
reassuring – or consistent for that matter. Even on June 11, customer service said that Providence Saint
Joseph Med. Ctr. was IN-network. When I was transferred to Claims, Claims said just the opposite.
If Providence Saint Joseph were to take the position that I, alone, am responsible for confirming network
status, my response would be that I did so (to the extent possible as a Blue Shield customer). I put it
that way, because it does not matter what I confirm – the real confirmation is done between the
provider and Blue Shield. THAT is why I warned Saint Joseph about the inconsistent answers coming
from Blue Shield. THAT is why Admitting assured me that Financial would confirm any network
problems before performing the emergency procedures on May 23 and call me if there were any.
Whereas I was able to climb 10 flights of stairs the previous week, I was no longer able to do so, even
after the cardioversion. Even talking or walking through the house was leaving me short of breath. I
was in need of surgery. I was also at risk of slipping back into A-fib at any time and possibly throwing a
clot to my brain. I was on a blood thinner and a drug to lower my heart rate and blood pressure to my
usual, historical levels of 115/75 at 65 bpm while I waited for answers from Blue Shield about my
petition for “Continuity of Care”, which I applied for on June 2 so that I could deal with my condition
promptly. I was told I could expect a decision by June 11 (5-7 business days). That did not happen. My
appeal to get me into a better network (so as not to lose my providers) was filed on May 27, and there
was no response to that either, as of a June 25 check of P.O. box.
While I was under this Sword of Damacles I had to look for a new, unknown cardiologist, a cardiothoracic surgeon, imaging technicians and a hospital that were ALL in-network. Only then could I
undergo surgery to repair my mitral valve and ruptured heartstring. I found such a combination at Keck
Hospital of USC in downtown Los Angeles.
I got an angiogram Thursday June 12. Tests and records were sent to Keck. I had to wait for an
consultation in the Cardio Thoracic Department. I got that on July 1 with Dr. Craig Baker.
I cannot possibly be the first (or only) patient to be going through this. This failure of Blue Shield to
inform me of their intent to place me in a Covered CA network of providers was unconscionable. Blue
Shield’s misrepresentation of their insurance product caused considerable confusion for me and my
providers, as well as expense for me and undo risk to my health and life.
On June 11 I asked for a new letter from Blue Shield Claims Department. They said they I would be able
to show the letter (which they promised would arrive in 10 days) to providers, but I still don’t see that it
would change anything, because they are still going to check with Blue Shield as to confirm their
network status. Blue Shield Claims further said that providers are confused or unaware that they need
to contract with Blue Shield to service these new networks. I countered that Blue Shield is confused and
unaware that one Blue Shield department says that providers are in-network while other Blue Shield
departments say that they are not.
My Blue Shield application makes one statement about Covered CA : “To enroll or modify coverage
obtained through Covered California, contact Covered California directly.”
I have read my Blue Shield Preferred PPO Statement of Benefits & Coverage, and it does not mention
Covered CA networks at all.
Blue Shield withheld vital information in its product marketing and recruitment. It is responsible for
inconsistencies in its marketing and recruitment and in the documentation and search results available
to customers on their website as well as answers from Customer Service. Their failure to mention their
use of a “mirrored Covered CA network” for their Preferred PPO plans cannot be anything less than
fraudulent. Providence Saint Joseph’s part in this is the simple negligence of their Financial department
for not notifying me that there was a problem with the insurance. My cardiologist messed up in not
knowing that he was not contracted for my PPO network and in not stressing in his dictation the
emergency nature of the events of the week of May 19 – May 23.
-------------------------------------------------------------------------------------------------------------------------------
Blue Shield PPO Plan
INDIVIDUALS
Blue Shield of CA
Preferred PPO (Gold)
0 / 20
Per Month
789.44
Per Year
9,473
Deductible
0 Yearly, 0 Drugs
Out-of-Pocket Max/Yr.
6,350
Preventative Care Copay
Periodic, Free
Primary Dr. Office Visit
30
Specialty Dr. Office Visit
50
X-Rays (most)
50
Lab Tests (most)
30
MRI, CT, PET
20% Coinsurance
Outpatient Surgery
20% Coinsurance
Inpatient Hosp Surgery
20% Coinsurance
Mental Health Visit Outpatient
30
Plan Pharmacy, up to 30-day supply
Generic Drugs: $19 Copay
Brand Name Drugs: $50 Copay
Non-Formulary Drugs: $70 Copay
Special Drugs: 20% Coinsurance
Emergency Room
$250 Copay. Ambulance = $250 Copay
Urgent Care
60
Out-of-Network Cover
Yes, see brochure
Out-of-Country Cover
NO
Skilled Nursing Facility
20% Coinsurance, 100 Days per Benefit Period
Home Healthcare
20% Coinsurance, 100 Visits per Year
Chiropractic Coverage
Not Covered
Durable Medical Equip.
20% Coinsurance
Hospice
"No Charge"
Out-of-Network Authorization Required
YES
Out-of-Network Annual Deductible
$0
Out-of-Network Annual Coinsurance
50%
Out-of-Network Out-of-Pocket Yr/Limit
9,350
Lifetime Maximum
Unlimited Lifetime
For a list of participating providers, see www.blueshieldca.com or call 855-836-9705.
Blue Shield search result showing St. Joseph as IN-Network.