Flu shot claim at in-network clinic processed as out-of-network

I am in Kentucky.

My insurer is BCBS of Illinois (where my employer is headquartered). Not sure if the difference matters.

This is going to be a wall of text for a relatively low stakes claim, sorry about that but I just don’t know which details matter anymore.

So, recently I went to get a flu shot at one of those kiosk clinic locations inside Kroger stores (The Little Clinic). I was told up front that they accept BCBS insurance. I got my shot as planned. This week, I got a bill from them for $95 indicating that my insurer did not cover any part of the cost. On looking at my EOB for the claim, it was processed as out of network. I called one of their customer advocates to try and learn more about what was up, and the situation started to get weird.

So the first advocate I spoke to, yesterday, said that the NPI number that the clinic billed under did not match what they had on file and would have expected. He advised I call the clinic and ask about it, gave me the NPI that BCBS expected, and arranged to call me back the next day (today).

I called The Little Clinic and told them what the BCBS advocate told me. The rep I was speaking to said that she did not recognize the NPI I was given at all, and that the one they used was the same statewide.

The advocate from BCBS called me back today and I relayed that to him. He put me on hold while he made a series of phone calls to various departments at The Little Clinic. He eventually concluded that they did not actually have a contract with BCBS, and they were truly out of network.

I assumed at this point that this was my bad, that I had misunderstood what it meant that the clinic accepted BCBS insurance. I asked the advocate how to identify a clinic location where I wouldn’t have this issue, he walked me through the provider finder on their website, and we found a Walgreens location nearby as an example for the next time I want something like a flu shot. We end the call, and then it occurs to me to search their provider finder for the location I used, expecting that it wouldn’t come up.

Except it did. The Little Clinic location where I got my shot is listed as in my network. Now, $95 is pretty low stakes as medical bills go, and I’m very fortunate in that I could spend that amount without worrying much about it. But at this point it bothers me on principle. Their website, using the process they just walked me through, is telling me I would be good to go at that location.

So I called back and got advocate #2. This time it went a little differently. She was the first to acknowledge the difference between BCBS of Illinois and BCBS of Kentucky. I don’t know what the difference is, but as I understand it providers are directed to submit claims through local BCBS regardless. So her approach was to contact BCBS of KY and inquire about the clinic’s status in their system. I was on hold for a while and when she came back, she said that even though the clinic is in network, the specific person who gave me the shot is not. After all the earlier discussion of NPI number mixups, I’m not sure how to reconcile what seems to be an entirely different conclusion.

On top of that, it strikes me as ridiculous that for something as simple as a flu shot, even though the clinic is in-network, they apparently expect members to contact the clinic and ask for the name of the specific person who will be giving the shot, because their status must be verified separately.

Is this truly the way this system works, or am I missing something here? Paying for this isn’t going to break me, but boy am I on fire thinking that any other member might land in the same situation even after looking up the clinic in the provider finder.

submitted by /u/ProfessionalArugula0
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I am in Kentucky. My insurer is BCBS of Illinois (where my employer is headquartered). Not sure if the difference matters. This is going to be a wall of text for a relatively low stakes claim, sorry about that but I just don’t know which details matter anymore. So, recently I went to get a flu shot at one of those kiosk clinic locations inside Kroger stores (The Little Clinic). I was told up front that they accept BCBS insurance. I got my shot as planned. This week, I got a bill from them for $95 indicating that my insurer did not cover any part of the cost. On looking at my EOB for the claim, it was processed as out of network. I called one of their customer advocates to try and learn more about what was up, and the situation started to get weird. So the first advocate I spoke to, yesterday, said that the NPI number that the clinic billed under did not match what they had on file and would have expected. He advised I call the clinic and ask about it, gave me the NPI that BCBS expected, and arranged to call me back the next day (today). I called The Little Clinic and told them what the BCBS advocate told me. The rep I was speaking to said that she did not recognize the NPI I was given at all, and that the one they used was the same statewide. The advocate from BCBS called me back today and I relayed that to him. He put me on hold while he made a series of phone calls to various departments at The Little Clinic. He eventually concluded that they did not actually have a contract with BCBS, and they were truly out of network. I assumed at this point that this was my bad, that I had misunderstood what it meant that the clinic accepted BCBS insurance. I asked the advocate how to identify a clinic location where I wouldn’t have this issue, he walked me through the provider finder on their website, and we found a Walgreens location nearby as an example for the next time I want something like a flu shot. We end the call, and then it occurs to me to search their provider finder for the location I used, expecting that it wouldn’t come up. Except it did. The Little Clinic location where I got my shot is listed as in my network. Now, $95 is pretty low stakes as medical bills go, and I’m very fortunate in that I could spend that amount without worrying much about it. But at this point it bothers me on principle. Their website, using the process they just walked me through, is telling me I would be good to go at that location. So I called back and got advocate #2. This time it went a little differently. She was the first to acknowledge the difference between BCBS of Illinois and BCBS of Kentucky. I don’t know what the difference is, but as I understand it providers are directed to submit claims through local BCBS regardless. So her approach was to contact BCBS of KY and inquire about the clinic’s status in their system. I was on hold for a while and when she came back, she said that even though the clinic is in network, the specific person who gave me the shot is not. After all the earlier discussion of NPI number mixups, I’m not sure how to reconcile what seems to be an entirely different conclusion. On top of that, it strikes me as ridiculous that for something as simple as a flu shot, even though the clinic is in-network, they apparently expect members to contact the clinic and ask for the name of the specific person who will be giving the shot, because their status must be verified separately. Is this truly the way this system works, or am I missing something here? Paying for this isn’t going to break me, but boy am I on fire thinking that any other member might land in the same situation even after looking up the clinic in the provider finder.
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