DRG 492 – PPO VS Medicare VS Cost Plus

We received an interim claim this afternoon on an in-patient hospital admission (motorcycle accident) in the Rio Grande Valley (Texas). The patient was admitted about a week ago, and is still in the hospital, expected to be in the hospital for another two or three weeks. Due to stop loss issues, an interim bill was requested for prompt payment prior to expiration of the stop loss policy which is Jan 1, 2012.

This interim hospital bill so far is billed at $204,000 for charges through today. It was quickly repriced through the PPO contract in place, and the allowed amount comes to $142,000, for a whopping 29% discount off billed charges.

Medicare would have paid about $16,862.07 for DRG 492 (http://www.findacode.com/drg/492-lower-extrem-humer-proc-hip-foot-femur-drg-code.html ).

The hospital billed amount equals to about +1,200% of Medicare.

The PPO allowed amount equates to about +842% of Medicare.

Our Cost Plus program would have paid about $21,000 on this claim (www.costplusinsurance.com )

But, this claim is continuing as of this writing, and will be even more than what has been billed so far. So the numbers will look even worse for a PPO/Medicare/Cost Plus comparision.

Editor’s Note: This claim is not uncommon. We see claims like this every week. The problem is, consumers don’t see these claims and dont care. They have insurance!  Yet it is the hated, greedy insurance companies that take the blame for ever increasing health care costs. Isn’t that like blaming gas stations for the high price of gasoline?  You decide. Managed Care Under Siege – explains our take on our medical care delivery system. We welcome opposing views – write riskmanager@sbcglobal.net

From a Texas insurance consultant:

Bill, this is a good example of what an outlier in a PPO contract will do. I expect the outlier in this case is $100,000. Since the billed charge exceeded that threshold, it is no wonder the discount was so small. If this case had no PPO contract, and paid Medicare rates, balance billing could be handled as easy as dickering with a used car salesman. I bet a 20 minute phone call could have reduced this bill by 50%, much better than the 29% discount this claim received. This whole health care reimbursement system is Bull Shit.

From a Midwestern insurance consultant:


From a San Antonio business owner:

This isn’t ‘highway’ robbery; it’s a home invasion personal robbery!!