Move Over BCBS, Aetna, UHC & The Rest – Lisa Gets The Best Prices, Yours Suck

Hey Doc, how much will you charge, cash, for a Carpal Tunnel Release?. If I like it I’ll pay you in full on the day of service……………………or before if you insist.

A Cash Pay Centric Health Plan removes the TPA from the Spoke of the Wheel, replaced by the Plan Sponsor who manages and approves all Cash Managed claims. This could be anything from an office visit to an MRI to a surgical procedure and hospital encounters including in-patient stays. Cash managed claims include pre and post service claims.

Below is a professionally done schematic showing the strategy (Hey, Southwest Airlines was started on a cocktail napkin wasn’t it?)

This afternoon we received a request for a funding approval for an upcoming medical procedure. This is an example of what some providers are willing to accept in lieu of running claims through managed care contracts or Reference Based Pricing plans.

In our experience providers accepting <120% of Medicare for cash is common. In some cases providers have agreed to accept payment below Medicare rates. They don’t have to deal with insurance companies or chase patient share.

Plan members pay nothing – all patient financial responsibility is waived because the plan pays it all. Deductibles are silly because Everyone Is Paying For Mary’s Deductible Because Mary Isn’t)

Below is the cash paid claim calculation for an upcoming procedure for a plan member in Texas. The date of service is 1/4/21. The price for the procedure comes out to 68% of Medicare for a Carpal Tunnel Release; Right.

Provider (CPT DRG) Medicare Price Cash Price % of

Medicare

Surgery Center 64721×1 $1,719.35 $771.37 44%
Provider #2 01810×1 $250.00 $322.00 128%
Claim Management Fee Case Fee $0.00 $250.00 0%
Total Price: $1,969.35 $1,343.37 68%
We call this The Lisa Plan because she developed it. Her company earned a $250 management fee on this claim.
RiskManagers.us is a specialty company in the benefits market that, while not an insurance company, works directly with health entities, medical providers, and businesses to identify and develop cost effective benefits packages, emphasizing transparency and fairness in direct reimbursement compensation methods.
 
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