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Broker News | October 2015 | Special Issue
Broker News | October 2015 | Special Issue

Excellus Blue PPO Out-of-Network Pricing

The Health Plan is working to streamline and simplify our out-of-network pricing methodology for all of our product lines.  Today, our HealthyBlue and SimplyBlue products use a percentage of Medicare payment allowances.  Our Excellus BluePPO products use a more complex pricing system, using the lesser of at least three different pricing mechanisms.  As we make the transition to the simplified pricing for Excellus BluePPO, we'd like to give you some details on this transition. 

First, please note that, on average, fewer than two percent of our total claims volume is truly provided out-of-network.  We analyzed the top out-of-network services received.  In general, our non-participating providers (those in the Excellus BlueCross BlueShield service area) will be reimbursed at thirty percent less than what they would have paid been under the participating provider allowance.  In addition, out-of-area non-participating providers will be paid about forty percent less than the participating provider allowance.  Members will be subject to balance billing for services rendered by non-participating providers.  We anticipate that this transition will encourage use of in-network services.  Please note that emergency services are not subject to this change. 

For the majority of our Excellus Blue PPO business, we are applying an eighty percent (for in-area) and one hundred fifty percent of Medicare allowance (for out-of-area) pricing system.  Groups wishing to discuss this transition should reach out to their broker, consultant or account manager to learn more about the options available.  Some groups have unique pricing methodologies that will continue to be applied and won't be adjusted. 

For groups that have Excellus Blue PPO, this change will be made upon renewal.  Please talk to your broker, consultant or account manager if you have any questions. 

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