04/23/2025    

RESPONSES/COMMENTS (INSURANCE COMPANY ISSUES)

RE: Office Visit Co-Pays: Specialists vs. PCPs  (CA Blue Shield)

From: Keith Gurnick, DPM

 

In an outdated method to financially punish their insureds and place yet another barrier to specialist care, most health insurance companies on many of their plans require higher office visit co-pays when a patient is seen by a specialist. Why should an insured patient be required to pay more out-of-pocket, for the "luxury" of care provided by a specialist doctor, who everyone knows is more qualified to treat their condition, when specialized care is medically indicated and necessary?

 

Most PPO insurance plans have different office co-pay requirements depending on if the patient is seen by a PCP doctor or a specialist. The office visit co-pay is almost always higher when the patient is seen by a specialist. The co-pay amount, due and paid by the patient, is then subtracted from the contracted allowable amount when the insurance company processes the claim and makes payment to the doctor.

 

As an example, Aetna, Anthem Blue Cross, Cigna, HealthNet, UnitedHealthCare all consider a podiatry visit as a specialist visit for the purpose of charging and collecting the co-pay amount shown on the ID card or on the company website. However, Blue Shield for some unknown reason continues to process podiatry claims as if the patient was seen by a PCP doctor and not a specialist. Why doesn’t Blue Shield classify podiatrists as specialists when it comes to claims processing, including the required collection of co-pays as a specialist? Podiatrists are certainly not PCPs. How can we fix this? 

 

Keith Gurnick, DPM, Los Angeles, CA

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04/24/2025    

RESPONSES/COMMENTS (INSURANCE COMPANY ISSUES)

RE: Office Visit Co-Pays: Specialists vs. PCPs  (CA Blue Shield) (Keith Gurnick, DPM)

From: Kristin E Happel

 

Insurances process claims based on what taxonomy code has been assigned to the provider during the credentialing process. If they are credentialed as a specialist with a particular insurance, then a specialist copay will apply to claims. If they have been mistakenly credentialed as a PCP/IM doc (it happens more than you would think), then a lesser co-pay (sometimes no co-pay) will apply.

 

I urge every DPM to make sure that they have been credentialed as a DPM, and not as a PCP/IM with all their insurances. If there is a particular insurance that is mistakenly assigning the wrong co-pays, contact them directly to correct this. 

 

Kristin E Happel, Medical Biller, Crystal Lake, IL