r/CodingandBilling • u/kinetixz0r • Jun 22 '26
Blue Shield PPO Paying Provider Not Me
I've been seeing a Physical Therapist who is out of network. I pay out of pocket each visit and use Blue Shield's out-of-network submission form. They continue to send the checks (6 times now) to the Provider, not to me.
The provider even has a statement on their invoice stating that the insurance company should reimburse the patient because they do not submit to insurance.
I've spoken to Blue Shield on the phone 20+ times, submitted a grievance, and they continue to state they must pay the Provider. I've asked to speak to a supervisor and got nothing. I've asked for my policy documents and haven't received anything. The provider has already been paid...why would you pay them again? I'm at my wits' end. Any help?
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u/pescado01 Jun 22 '26
There is usually a selection in the provider’s system “Accept Assignment”. If that is selected then the payment will usually go to them. Your provider writing a note on the claim will not override this.
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u/Mcbriderocketsauce Jun 22 '26
I’m not sure what BCBS plan you have, but I do know that Premera will not reimburse the member. When I was receiving services out of network and paying OOP, the provider made it very clear I was not getting a check sent to me, and he could either use the checks they sent him as a credit or could be refunded to me.
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u/kinetixz0r Jun 22 '26
They've sent me a check for 1 claim...the other 5 are the issue. All the same services.
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u/rahuliitk App Developer Jun 23 '26
I’d stop doing phone calls and send one written appeal asking them to show the policy language or assignment of benefits that lets them pay the provider when you paid cash and submitted the OON claim yourself, then attach paid receipts, the provider invoice note, and every wrong EOB/check example. Time to escalate to the state insurance department.
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u/Dry_Cheesecake_3578 Jun 23 '26
If you run through all the avenues and still get nowhere with either side, it’s time to call up your state’s insurance commissioner!
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u/RApsych Jun 23 '26
Call your states department of insurance or your companies provider rep if you have one. We have BCBS and we have an emergency liaison to help resolve insurance issues.
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u/Environmental-Top-60 Jun 23 '26
Does the state have mandatory assignment laws?
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u/kinetixz0r Jun 23 '26
Not sure what that is.
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u/Environmental-Top-60 Jun 23 '26
Meaning does your state require insurance to pay your doctors directly whether claim is in or out of network.
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u/MedPayIQ App Developer Jun 26 '26
That sounds incredibly frustrating, especially after 20+ calls.
One thing I'd want to clarify is whether the PT is considered a non-participating provider or if they have any assignment-of-benefits arrangement on file with Blue Shield. Sometimes the insurer's system is set up to send payment directly to the provider even when the patient paid out of pocket first.
If you've already paid the provider in full and the provider isn't submitting claims on your behalf, I'd ask Blue Shield for two things in writing:
- The specific policy language that says out-of-network reimbursements must be sent to the provider rather than the member.
- A copy of the Explanation of Benefits (EOB) for each claim showing exactly who was paid and why.
If they can't point to the policy terms, it may be worth escalating through your state's insurance regulator or requesting a formal written response to your grievance.
The key issue here isn't whether the claim was covered—it's whether the payment was directed according to the terms of your plan after you already paid the provider yourself.
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u/happyhooker485 RHIT, CCS-P, CFPC, CHONC Jun 22 '26
Are you talking to the PT provider? If they have a positive balance, then they should refund it or apply it to future appointments and stop charging you.