The Difference Between A BUCA and an Independent TPA Can Be Stark

stark

A recent request from one of our clients to their record keeper was simple; What have we been paying, on average, for certain procedures? The response/s in a string of emails lays out a simple request into one of enormous complexity, seasoned with a good dose of Bull S–T.

By Bill Rusteberg

Self-funded plan sponsors hire a record keeper to track and record claims, among other duties. Some record keepers are better than others. Some are insurance companies and some are independent third party administrators. There can be a stark difference between the two.

A plan relies on their record keeper to provide claim data which can be important to proper risk management and fulfilling fiduciary duties.

A recent request from one of our clients to their BUCA record keeper was simple; What have we been paying, on average, for certain procedures? The response/s in a string of emails lays out a simple request into one of enormous complexity, seasoned with a good dose of Bull S–T.

TO BUCA REPRESENTATIVE FROM SELF-FUNDED PLAN SPONSOR

Hi (BUCA Representative)

Can you provide the following information:

  1. The average cost to our plan for well-woman exams. (I think they fall under the following codes: 99213, 99214, and 99215)
  2. The average cost of general office visits. (I think the fall under the following codes: 99203, 99204, and 99205)

Thank you for your help.

FROM BUCA REPRESENTATIVE (TWO WEEKS LATER)

I am trying to find a way to price this without a claim and I had to do some digging.  I have found some options to get this pricing done in a generic method.

I am awaiting to see when this comes back I hope no later than Thursday then I can see if it appears to give what you are seeking. Thanks for your patience on this.

FROM RISKMANAGERS.US TO BUCA REPRESENTATIVE (TWO SECONDS LATER)

Seems to me that as plan record keeper you should be able to pull up all claims from your system specific to (Name of Group) and give us detailed data immediately. Otherwise it is rather difficult to make informed decisions on our end.

I don’t think what we are asking for is out of the ordinary. Or is it?

FROM BUCA REPRESENTATIVE (24 HOURS LATER)

We do not typically give out a raw data dump of all claims unless there is a Vendor set up that can manage the data for example a Zywave relationship type.

I would say that it is not a typical request on what we usually see.  There is a HIPPA data that even we have to protect when it comes to diagnosis specific to member detail or specific test that could have been ran alongside an office visit.

The raw data pull takes about 7-10 days it can come in sometimes in 4-5 days but not always and then we have to run through it and get rid of all details that cannot go out.  Then you have to know how to read our coding that is on the raw data file that shows in network versus out of network to know if it was a negotiated fee or a reasonable and customary limit.

There is more involved than it may seem, I wish these things were simple.

I have a report that gives us some data I have pulled, it is more of an all-in look at office visits.

I have the claims area response back this morning to get us some figures to work with.

CPT                        R&C Rate

99213                    $59.10

99214                    $87.24

99215                    $117.74

99203                    $87.45

99204                    $134.14

99205                    $168.51

Thanks, I hope this may be helpful.

FROM RISKMANAGERS.US (MILISECONDS LATER)

Excuse my bad manners but your response is BS

This sad story is not intended to indict the BUCA’s in general. Some are more cooperative than others. All have the ability to respond appropriately, but the problem of not doing so as in this case is usually tied to who one is dealing with and at what level. Sometimes a change in a group representative brings night into day, and sometimes the opposite is true.

Independent third party administrators, on the other hand, are adept at providing real time records without complaint or hidden agendas. After all they are record keepers aren’t they? They can even benchmark claims against universally used data points such as Medicare allowable to enable a plan sponsor to determine the value of their PPO “discounts.” A BUCA would never do that.

FANMAIL

 

From Director of Risk Management – Texas School District

Bill, your article is very accurate.  Getting Congress to act on an issue is a breeze compared to receiving data from the blues.

 

 

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