Before You Sign With a Company Promising BCBS Reimbursement, Ask One Important Question

One of the most common questions we hear from IBCLCs is:

"My local Blue Cross Blue Shield plan won't credential me. A company says they can get me paid anyway. Should I sign?"

Before you do, it's important to understand how Blue Cross Blue Shield claims generally work.

Blue Cross Blue Shield Is Not One Insurance Company

Many providers think BCBS is a single nationwide insurer.

It isn't.

The Blue Cross Blue Shield system consists of independent, locally operated companies. Each plan establishes its own provider credentialing policies, participation requirements, reimbursement rules, and covered services within its service area.

That means an IBCLC who is eligible to participate with one BCBS plan may not be eligible under another.

Claims Follow the Provider's Local BCBS Plan

When services are furnished, reimbursement is generally determined according to the rules of the provider's local Blue Cross Blue Shield plan, even when the member is insured through a different Blue plan. The BlueCard program is designed to route claims between Blue plans while allowing the local plan's provider participation and reimbursement rules to be applied where appropriate.

For IBCLCs, this means the first question is usually:

Does my local BCBS plan recognize and reimburse my provider type?

If the answer is no, that raises an important question.

How Is Another Company Getting Paid?

If your local BCBS plan does not credential or reimburse your provider type directly, and another company tells you they can "get you paid," ask them to explain exactly how that works.

Questions worth asking include:

• Under whose NPI is the claim submitted?

• Under whose tax identification number (TIN) is the claim billed?

• Who is the rendering provider on the claim?

• Who holds the BCBS contract?

• Is there a delegated network or other contractual arrangement?

• How does the billing model comply with the applicable payer's billing policies?

• Will I have access to my claims, remittance advice, and explanations of benefits?

A reputable company should be able to answer these questions clearly and transparently.

If You Don't Understand the Billing Model, Ask More Questions

Healthcare billing is heavily regulated.

Practices should understand exactly how their claims are being submitted and why the payer recognizes that billing arrangement.

If someone tells you:

"Don't worry—we have a special way of getting these claims paid."

Ask for an explanation.

You should understand:

• Why the payer accepts the claims.

• Which provider is actually billing.

• Whether you remain responsible for the documentation.

• Whether the arrangement complies with the payer's provider agreement and billing requirements.

If the explanation isn't clear, don't be afraid to seek advice from a healthcare attorney or qualified compliance professional before signing a contract.

Transparency Protects Everyone

There are legitimate business models that help providers navigate insurance reimbursement.

There are also arrangements that are poorly explained, leaving providers uncertain about who is actually billing for their services or why claims are being paid.

As the rendering provider, your professional reputation and your documentation are tied to those claims.

You should never feel uncomfortable asking questions about how your services are billed.

The Bottom Line

If your local BCBS plan does not currently credential or reimburse your provider type, be wary of anyone offering a simple solution. If they can't clearly explain how their billing process works, it should raise concerns.

That doesn't automatically mean the arrangement is improper—but it does mean you should understand exactly how the claims are being submitted, who is billing them, what contractual authority supports the arrangement, and whether the billing model complies with the applicable payer's requirements.

The best billing partner is one that is completely transparent—not only about what they do, but about how they do it.