“Readers digest version: if you try to bring in your own oversight, you’ll either face enough friction to give up—or pay steeply for the privilege. Whether the intent is deterrence, revenue extraction, or both, the result is the same.”
By Cris Deacon
Today I’m taking a closer look at how Health Care Service Corporation, one of the largest Blue Cross Blue Shield Association carriers in the country, handles employers who want to engage third-party claim review companies.
Readers digest version: if you try to bring in your own oversight, you’ll either face enough friction to give up—or pay steeply for the privilege. Whether the intent is deterrence, revenue extraction, or both, the result is the same.
They are rolling out a new product called the Direct to Client (DTC) Program. This DTC Program will be mandatory for any employer that wants to bring in an outside payment integrity vendor instead of relying solely on HCSC’s Advanced Payment Review (APR) program.
Their terms, take it or leave it:
▪️ You don’t get to choose between APR and DTC—you pay for APR and DTC.
▪️ The “privilege” of reviewing claims comes with a steep price: $861 per case reviewed and $2,638 per pre-pay flag request. For large employers, those charges can quickly become prohibitive.
▪️ Payment integrity vendors are limited in what they can review—no medical necessity reviews and even pre-pay flags require HCSC’s approval.
▪️ Everything must still run through HCSC: reporting, communication, escalation—all controlled by the carrier.
Does anyone else find this absurd: employers already pay HCSC to process claims correctly the first time. But, because there are costly errors and overpayments, the employers have to pay again for an outside vendor to catch and correct them. Now, HCSC wants a third bite at the apple—charging employers for the privilege of reviewing the work of the vendor who was only necessary because of HCSC’s own errors.
It’s a pay-to-fix-what-you-already-paid-for loop that defies logic.
Who else is seeing these demands? How are your clients pushing back? Are there other demands being made out there that I’m not aware of? I want to hear from you.
(Note: this language has been adapted for confidentiality, but it accurately reflects the conditions and terms clients have been presented with.)
