By Bill Hennessee
Question: What prevents all of the best healthcare savings solutions to be implemented in large self-insured companies?! Answer: The TPA network agreement.
So get out all of the illegal clauses and those that favor the carriers and the hospitals. Here’s some hints:
1. CPT codes are proprietary to the carrier. No – they are owned by the AMA. Take this out.
2. NPI numbers are proprietary to the carrier. No – they are owned by CMS. Take this out.
3. Carrier reserves the right to negotiate out-of-network claims. Add the word “lower” here, or else they will negotiate to pay above billed charges so they can make money with their hospital friends at your ignorant expense.
4. Carrier reserves the right to approve your claims auditor. No – you do. They are your claims. You also have the ERISA fiduciary.
5. Carrier limits claims to be audited to 3% of claims. No – that’s a 97% breach of fiduciary. Look at 100% of claims every year.
6. Auditor and carrier sign a proprietary agreement that you cannot review. No – make certain you see the agreement as you do not want the auditing agreement to prevent you from being told everything.
7. Carrier will properly pay claims. Suggestion: define “properly” by stating: Inpatient claims will be paid by DRG codes. Outpatient claims will be paid by CPT codes. No revenue codes will be used for payment. This is what Medicare does as largest payor of healthcare. Revenue codes are not billing codes.
8. Blue Card by Blue Shield. Get it in writing the flat fee or percent of care fee dollar amount for each of the 8 Blue Card fees
a. Care coordination fee
b. Access fee
c. Administration expense allowance fee
d. Per prescriber per month fee
e. Nonstandard fee
f. Central financial agency fee
g. Inter-plan teleprocessing transaction fee
9. Aetna. Cannot steer care in-network. Remove this sentence. And why isn’t Aetna helping steer to save? Or getting one same low price per care item for all?! Aetna and the others permit over 1,000% pricing variation in-network for same care item. Your ERISA fiduciary says you have to help steer to better priced providers for routine care.
10. Cigna. Claims under $75,000 are a “just trust us” and pay our hospital friends. You are not allowed to ask for and review an itemized bill or medical records below this dollar amount. Remove this employer abuse for obvious fiduciary violations.
11. United. Discounts are proprietary and therefore you cannot access charge rates to figure out discount rates. Remove this type of language as ERISA anti-gag clause (29 U.S.C. 1185 et seq.) says you have the right to access all cost and quality data.
Don’t be bullied. Be the bull.
