We received an interim claim this afternoon on an in-patient hospital admission (motorcycle accident) in the Rio Grande Valley (Texas). The patient was admitted about a week ago, and is still in the hospital, expected to be in the hospital for another two or three weeks. Due to stop loss issues, an interim bill was requested for prompt payment prior to expiration of the stop loss policy which is Jan 1, 2012.

This interim hospital bill so far is billed at $204,000 for charges through today. It was quickly repriced through the PPO contract in place, and the allowed amount comes to $142,000, for a whopping 29% discount off billed charges.

Medicare would have paid about $16,862.07 for DRG 492 (http://www.findacode.com/drg/492-lower-extrem-humer-proc-hip-foot-femur-drg-code.html ).

The hospital billed amount equals to about +1,200% of Medicare.

The PPO allowed amount equates to about +842% of Medicare.

Our Cost Plus program would have paid about $21,000 on this claim (www.costplusinsurance.com )

But, this claim is continuing as of this writing, and will be even more than what has been billed so far. So the numbers will look even worse for a PPO/Medicare/Cost Plus comparision.

Editor’s Note: This claim is not uncommon. We see claims like this every week. The problem is, consumers don’t see these claims and dont care. They have insurance!  Yet it is the hated, greedy insurance companies that take the blame for ever increasing health care costs. Isn’t that like blaming gas stations for the high price of gasoline?  You decide. Managed Care Under Siege - explains our take on our medical care delivery system. We welcome opposing views – write riskmanager@sbcglobal.net

From a Texas insurance consultant:

Bill, this is a good example of what an outlier in a PPO contract will do. I expect the outlier in this case is $100,000. Since the billed charge exceeded that threshold, it is no wonder the discount was so small. If this case had no PPO contract, and paid Medicare rates, balance billing could be handled as easy as dickering with a used car salesman. I bet a 20 minute phone call could have reduced this bill by 50%, much better than the 29% discount this claim received. This whole health care reimbursement system is Bull Shit.

From a Midwestern insurance consultant:

Crooks!

From a San Antonio business owner:

This isn’t ‘highway’ robbery; it’s a home invasion personal robbery!!

With the passage of ObamaCare, the entitlement mentality continues to be fueled to even higher levels. Isn’t preventitive care supposed to be free……………………..

(more…)

“Fish said that a captive Allstate agent with a $1 million book of business will realize $90,000 in base revenues at 9 percent while an independent agent holding an Allstate contract earns $150,000. “How fair is that?” Fish asked.”

(more…)

AARP’s income from United HealthCare skyrocketed from 2007 to 2009, even as the recession was hitting, leaping from $284 million to $427 million during that time, a 50 percent jump. In 2010, those revenues soared even higher — to $670 million.

AARP makes the majority of its revenues from United’s supplemental insurance policies to seniors, including what is known as Medigap, which covers things for which Medicare does not pay. One of AARP’s many ads tells seniors that the insurance can help them protect themselves from some of what Medicare doesn’t pay.

Save up to thousands of dollars in potential out-of-pocket expenses with an AARP Medicare Supplement Insurance Plan,” the ad says.

But AARPs support for the Obama administrations new health care law, which calls for $500 billion in cuts to Medicare, critics say, makes it all the more likely people would need supplemental insurance, something AARP stands ready to provide. That move alone, as seniors began to go to Medigap insurance, increases AARP’s revenue over a 10-year period by $1 billion.

Editor’s Note: With ObamaCare and the minimum loss ratio requirement (MLR) how are association sponsored health plans affected like the Texas Association of Counties, Texas Municipal League and others who sponsor and market group health plans in Texas? After all, aren’t these entities acting as a broker? Will their compensation be included in the MLR calculation? Or is there a loophole to be seized?

RBRVS, the nation’s largest PPO network, announced today in a televised press conference that sales projections for 2012 will surpass 2011 sales by 100%. 

“We expect rapid growth in the first quarter of 2012, followed by significant increase in market share in the private sector in the second and third quarters” announced Molly Mulebriar, CEO of Blithering Strategies (BS) of Dime Box, Texas.

RBRVS is a national network of hospitals and doctors and other health care providers. To date, the largest payer of the RBRVS network is the Federal Government through their Medicare program. Recent polling data indicates that other payers are forecast  to endorse the network in large numbers in 2012.

Molly (Bull Dog)  Mulebriar, well known  insurance industry critic and rabid health care advocate,  expanded her comments after the press conference.   “We at BS are excited about the RBRVS PPO network. Payers will save money. Practically every doctor and hospital in the country is on the system. And more importantly, it is unlike any other PPO network in the country – It is transparent. It is proven. It offers  a win win situation for consumers.”

“We believe in transparency. We publish our fee schedule. Anyone can access our fee schedule at www.trailblazerhealth.com – no other PPO in the country shares this information with the public. They keep their fees secret. That is wrong, and the root problem with health care costs in this country!” noted Mulebriar in an emotional exchange with ABC news reporterette and former Blue Cross representative,  Sandy Ostrich.

When asked what she message she would  to send to employers who sponsor group health insurance plans, Mulebriar responded “if you want transparency,  and willing to take your head out of the sand, Sandy, the RBRVS network should be the network of choice without question.”

For more information on the RBRVS PPO network, write RiskManager@sbcglobal.net

From a Mid West Insurance Consultant:

ooh baby…I’m all in on this one. where do I buy stock? Obama HQ?

Creation

Editor’s Note: A good laugh now and then is good for the soul