BUCA Document Exposes Out-of-Network Reimbursement Strategies

mulebriar

Part of a continuing series………..(See previous two posts)

“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 (see previous post) details inner workings of a 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.”

onehundredpercentSUMMARY: This BUCA, in some cases, pays Cost +100%. At that rate balance billing will be extremely rare.

How many businesses do you know that earn a markup this high, and still remains in business?

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