Can Anyone Explain This to Us?

Here we go again…………..our office was asked to investigate a provider claim to determine if the billed charges were fair and reasonable. The provider is a radiology group in a large metropolitan area in Texas.

The provider’s billed charges were, on average, +370% of 2008 RBRVS. We ran the charges through a large PPO network and discovered the billed charges were reduced down to +235% of 2008 RBRVS. This significant “discount” would certainly look good on an EOB. It would also look good on a year-end PPO claim anaylsis report. You would think that the PPO people really negotiated a great deal for you, right?

However, on behalf of the employer’s self-funded group medical plan, we have negotiated fees of 115% of 2008 RBRVS with similar providers in the same geographic area.

So, why would you want to pay a bill that is 120% higher for the same exact service you could get from a provider just down the street? Can anyone explain this to us?    

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