Archive for February 22nd, 2009

Why Would You Pay $3,000 for Something That Costs $100?

Sunday, February 22nd, 2009
Health care is a commodity. Would you pay almost $3,000 for something that you could get for about $100? See redacted email sent last week to one of our clients:
Ive read the letter from Mrs.XXXXXXXX and have reviewed the bills you sent us. This is a perfect illustration of what is wrong with our health care delivery system and with consumer perceptions / expectations.
 
For the first time, it appears that the consumer is questioning her medical care bills. This is a good thing. Before, consumers were used to simply paying their co-pay/deductible/co-insurance and the insurance company would take care of the rest. And therein lies the problem. What the consumer did not know, or even care about, was what the provider was charging for services. Employers and employees were content to assume that the PPO networks had successfully negotiated significant “discounts” on their behalf. But, what we have found through two years of study and investigation, PPO networks have become nothing more than a smokescreen that allow providers to inflate their fees. PPO networks directly contribute to continued escalating medical costs.
 
One example of price gouging by a provider can be found on one of the claims you sent to us. A tissue exam by a pathologist was billed at $2,827.31. Yet, Medicare would have paid this provider only $97.69. That is a 3000% markup from what the Federal Government would have paid under the Medicare program. We have agreements in place with physicians who would have accepted $112.35 as payment in full.
 
In looking at the other bills, I find markups of anywhere from 250% to over 800% of Medicare.  Yet, locally in XXXXXXXX County, we have negotiated rates on your behalf of 115%-125% of Medicare with hundreds of physicians. They are quite happy with the arrangement with some even going as far as applauding what your company is trying to accomplish.
 
In our quest to learn about PPO methodolgies, we found that every PPO network we investigated negotiated dissimilar contracts with providers. For example, Dr. Smith may have negotiated a better contract than Dr. Jones down the street in the same specialty. Consumers did not care or even know about this – all they knew is that both physicians were “in-network” and all they had to pay to visit the more expensive Dr. Smith was $20 where they could have gone to see Dr. Jones who was less expensive, for the same $20 copayment. None of this makes any economic sense, yet we have continued to perpetrate this inefficient and costly system we call health insurance.
 
A good example of this can be found on two claims for the same procedure code (36415). One vendor billed $12 and your plan paid $3. The other vendor billed $21 and your plan paid $3. This shows that vendors bill different amounts for the same exact procedure. Under a PPO Plan, the consumer does not know this. And, they dont care because “insurance will take care of this for me.” Providers can markup their charges to any level they choose.
 
Your employees have a choice of which providers they can see. Employees will need to become more engaged in their health care costs and make prudent business decisions that are best for them. My suggestion to Mrs. XXXXXX is to engage her physician in a dialog relating to costs. This is a cash plan not an insurance plan – we are not employing an insurance company – we are marshalling money from (Employer)and from the employees to fund a medical care plan that will pay providers a fair and reasonable fee for services.  
 
In the past the only time the consumer complained about their insurance was when the rates went up every year.  And they mostly blamed insurance companies for this. They were right, but they do not know why they were right.
 
On Monday I am going to set aside time to call the providers to see if we can get them to agree to reduce their fees on these particular claims. Of course they do not have to agree to anything and can charge any amount they choose to charge.  
 
 

PPO Networks Can Be Smoke Screens for Inflated Fees

Sunday, February 22nd, 2009

Yesterday we received the following email from a third party administrator which illustrates how a PPO network can actually increase claim costs:

“Bill, here’s one for you. We had a non-network dialysis clinic treating on of our patients. Rather than taking the wrap discount , we audited the dialysis charges and paid the clinic on a cost-plus basis. After six months of accepting payments. the dialysis clinic sought out the network and got themselves in-network. The end result? Charges went up $200,000. Since we continued paying on a cost-plus basis the network contacted us and told us that we could no longer do that but had to accept the % off billed charges since they had a contract with the clinic. Our response to the network was that if they could convince the employer and the stop loss carrier that this is in their best interest then they would qualify as the best sales organization in the world. “