Merry Xmas Mulebriar!

Mulbriar receives unsolicited Christmas gift revealing best kept secrets of out-of-network reimbursement strategies among the BUCA’s…………………..

“Reasonable charges for inpatient and outpatient facilities generally equal twice a facility’s cost as reported by the facility to CMS….”

A document left unattended in a brown paper bag in front of our corporate offices on Christmas Eve details inner workings of two of the BUCA’s out-of-network pricing strategies.

This document outlines two reimbursement methodologies: 1) PPO network reimbursement pricing, 2) Non-network pricing including facility claim review and itemized bill review.

According to the document, the later (#2) “provides reasonable charge allowance review for most inpatient and outpatient facility claims where a PPO contracted rate is not available. The reasonable charge allowance is based on a methodology determined by us, which may change from time to time. Reasonable charges for inpatient and outpatient facilities generally equal twice a facility’s cost as reported by the facility to CMS, or if information is not available for a specific facility, we use the state average facility cost information.”

SUMMARY: This BUCA pays out-of-network benefits at Cost +100%. How many businesses do you know that earn a markup this high, and still remains in business?

In a separate file we found documentation of out-of-network reimbursement strategies for two of the four BUCA’s.

BUCA #1 pays 110% RBRVS for facility and professional services while BUCA #2 pays 105% RBRVS for professional services and a whopping 140% RBRVS for facility charges.

We are sending the envelop and contents to a forensic lab for further analysis………….

Molly Mulebriar is an investigative reporterette from Waring, Texas. A former Miss Texas and 1985 Central Texas Jalapeno Eating Contest winner, Miss Mulebriar’s mission is to expose and report on egregious health care pricing in this country. She is co-inventor of The Schuessler Stick and donates her share of royalties to Wikileaks. Visit her website at www.mollymulebriar.org

 

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