Archive for April 23rd, 2012

A Group Medical Plan Without A PPO & No Balance Billing Issues?

Monday, April 23rd, 2012

“Provider Freedom health plans allow you the full choice of health care providers without restrictions or penalties. There are no preferred providers or networks required. See the provider you choose!”

“You still receive the value of PPO-like discounts for all medical services. These discounts are arranged on your behalf directly with the provider of your choice to gain the highest level of discounts possible.”

“If there is a disagreement between your plan and a provider on the fee for a service, we will negotiate directly for you to ensure there is no “balance bill” to you for discounts taken. The only out-of-pocket expenses are normal deductibles and coinsurance. ”

Editor’s Note: This trend is growing. Many of our clients dropped their PPO networks several years ago and have since enjoyed significant savings.  For more information on how claims are negotiated and how balance billing issues  are resolved, write

Blue Cross Culls Network? Employers Customize Health Plans – An SBPPO?

Monday, April 23rd, 2012

 “The old model is not working,” BlueCross CEO Alphonso O’Neil-White said Wednesday .

BlueCross BlueShield of Western New York is teaming up with the region’s largest provider system to offer self-insured
employers with new tailored networks, in hopes of providing more efficient care that decreases costs.

The BlueCross and Kaleida Health initiative, which officials said is the region’s first integrated network of its kind, lets employers customize health plans, tailoring the doctors and hospitals covered under the plan, reported Business First.

“The old model is not working,” BlueCross CEO Alphonso O’Neil-White said Wednesday . “This is not the standard model where a health plan creates a product and throws it out there to the market.” See

BlueCross and Kaleida Health both admitted that the tailored networks will limit members’ choices of doctors and hospitals, but they believe the breadth and depth of services will lead to members accepting the restrictions.Although each participating employer’s health plan will differ, they will share common goals, for example, basing medical decisions on research, avoiding
unnecessary tests and procedures, tracking, using data to evaluate performance and stressing preventive care.

The initiative also could lead to BlueCross to create new provider payment systems, such as bundled payments that help cover non-reimbursed services, the insurer said.

Employer groups could begin creating their tailored plans in June and offering them to employees Jan. 1, Business

Editor’s Note: Is this is an SBPPO? – see , ,


Blue Cross Anti-Trust Probe Expands

Monday, April 23rd, 2012

The U.S. Justice Department is widening an investigation into alleged collusion and price-fixing between Blue Cross BlueShield health plans and hospitals in several states, the Wall Street Journal reports.

The investigation is focusing on whether certain Blues plans have struck “most-favored nations” deals with hospitals that would allow the increase of premiums while potentially locking out competition. Blues plans in six states and the District of Columbia have received civil subpoenas.

“The antitrust division is investigating the possibility of anticompetitive practices … in various parts of the country,” said a Justice Department spokeswoman.

Officials with CareFirst Blue Cross Blue Shield, which operates in Washington, D.C., Virginia and Maryland, has confirmed it has been subpoenaed by the Justice Department, as has Indianapolis-based WellPoint, Inc., the nation’s largest insurer and operator of Blues plans in Ohio and Missouri.

Last October, the Justice Department filed suit against Blue Cross Blue Shield of Michigan, claiming it had entered into deals with about half of the state’s acute care hospitals, essentially giving it favorable terms while requiring it charge other health
plans up to 40 percent more for charging for the same services.

In February, it sued United Regional Health Care System in Wichita Falls, Texas, claiming it used most-favored nation contracts to maintain rates 70 percent higher than other hospitals. The system settled the suit immediately, agreeing to drop the use of such contracts.

Blues Fined $1.6 Million For Fraudulently Concealed Fees – PPO Access Fee of 13.5%?

Monday, April 23rd, 2012

A circuit court jury has ordered Blue Cross Blue Shield of Michigan to pay the city of Holland $1.6 million for wrongfully charging it excess fees as part of an employee insurance program.

An Ottawa County Circuit Court jury ruled Blue Cross “fraudulently concealed” a 13.5 percent access fee on city employee
claims. For example, City Attorney Andy Mulder said, if an employee incurred a $100 medical bill, Blue Cross would charge the city for $113.50 without disclosing the administrative markup, reported the Grand Rapids Press.

Holland officials said they didn’t know about the fee until 14 years after hiring Blue Cross to run the program, as similar cases
against the insurer and other municipalities around the state went to court, the Holland Sentinel reported.

There have been at least 30 cases filed against Blue Cross over the fees throughout Michigan. “Most of them are pending in some fashion,” whether awaiting trial or on appeal, Holland attoney Aaron Phelps said, adding that Blue Cross hasn’t won any cases, noted the Sentinel.

Blue Cross said it will appeal the verdict. Spokesperson Helen Stojic said Holland officials knew of the network access fee
up front, despite claiming they were unaware for 14 years. “Not only were these fees known, the City of Holland received substantial discounts in hospital services which resulted in millions of dollars in savings in hospital costs for Holland taxpayers,” Stojic said, according to the Grand Rapids Press.

Editor’s Note: How does a consultant spread-sheet this?