Discussion on Cost Plus Claims Reimbursement Programs

Tim Johnson

There is a growing interest in our industry around reducing / negotiating Provider Billed Claims based on some percentage of Medicare, Cost to Charge Ratios, Percentile of U&C or a combination of them. I have thorourghly examined all aspects of this model and have my own thoughts, but would like to hear how the industry is either accepting or rejecting these concepts and why. I will restrain from expressing my opinion until I have seen others comment one way or the other. But I would like to get an idea from others on what they feel the growth of this niche will be, where and when it can or should be used etc…

Editor’s Note: We received this from one of our readers: Most of these guys miss the point.  An employer can pay what their plan design designates they pay.  The employee can be protected as a part of the plan in the great majority of cases.  When the employee can’t be protected it is unlikely that they will have the money to make additional payments anyway and if they manage the process correctly can basically stall collections processes indefinitely.   Hospitals are political lighting rods and have to be really careful whom they chase and how aggressively they chase as scrutiny is not on their side. 

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Health Care Costs Set To Soar

By Tomas Philipson

Nations around the globe are grappling with rising costs of health care. In the US, health care liabilities and the federal debt are on a trajectory that is difficult to sustain. As the figure below shows, the Congressional Budget Offices estimates that federal deficits under current law will continue to rise faster than tax revenue, mainly driven by health care liabilities.

So why is health care spending growing? The answer is simple: Providers charge more and we continue to blindly pay through secretive managed care contracts that contain annual escalator clauses, silly outliers based on outrageous charge master rates that no one ever pays, and  consumers who don’t care about health care costs because “insurance pays it all!”

Employing reference based pricing (www.ReferenceBasedPricing.us ), or variations such as Cost Plus Insurance (www.CostPlusInsurance.com ) or Medicare Benchmarking (www.valuebasedpricing.us ), health care costs can be reduced, not increased.

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40% Of Unisured In Mo. Qualify For “Free” Health Insurance

Elisabeth and Mark Horst, artists in Albuquerque who earn $24,000 a year between them, qualified for a zero-premium plan.

“The availability of the zero-premium plans varies across the country. McKinsey found that about 40 percent of the uninsured in Missouri will be able to select a no-cost bronze plan…”

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HHS Website Fixed – Exchange Open For Business

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The Obama administration announced today that the government health care exchange website has been fixed and is open for business. “Programmers, imported from Moscow, have successfully fixed the site”, said Ed Snowden, senior web analyst for Grotney Mosovich, a leading Russian web design firm. It is expected that 43 million new policies will be issued in the next several weeks through new and improved access to the site. Estimated on-line time to complete an application is 22 minutes.

Check out the website for the exchanges HERE