“If you have a BCBS plan, this is happening to you. It doesn’t matter what they promised in the RFP. It doesn’t matter what the glossy sales deck said. It doesn’t matter what they tell you in meetings. This document governs what actually happens to your claims. And once you read it, you’ll understand why fiduciaries should be very, VERY, uncomfortable.”
My family gets one present on Christmas Eve. This year, this is mine to you.
By Chris Deacon
Attached is a portion of the “Inter-Plan Arrangements” schedule used by Blue Cross Blue Shield Association (BCBS) plans for their ASO clients. (*Access to the entire Schedule is found in a longer more substantive Substack Article – link below*)
If you have a BCBS plan, this is happening to you. It doesn’t matter what they promised in the RFP. It doesn’t matter what the glossy sales deck said. It doesn’t matter what they tell you in meetings. This document governs what actually happens to your claims. And once you read it, you’ll understand why fiduciaries should be very, VERY, uncomfortable.
A few highlights directly from the contract:
🔹 You can be charged more than the provider billed. “In cases where the negotiated price exceeds the Billed Charges, Employer may be liable for the excess amount…”
Yes. More than billed. Let that sink in.
🔹 Prices may be ‘estimated’ or ‘average’ not real. Host Blues decide whether pricing is “actual, estimated or average,” based upon an undisclosed formula with any differences later trued-up through internal unsegregated “variance accounts” you don’t get to see, audit, or get refunds from at the end of your contract term.
🔹 Third-party recoveries can reduce refunds and you pay the fees. “The fees of such a third party may be charged to Employer as a percentage of the recovery.” No disclosure of entity, percentage of fee, or amounts paid.
🔹 Payments may not be recoverable if it would ‘jeopardize’ provider relationships. Recoveries may not occur if they would “jeopardize the Host Blue’s relationship with its Participating Providers.”
Yes – you read that right. If we don’t want to upset our providers, we won’t recover that $100,000 duplicate payment. I’m sure giving back 100k would be “upsetting” to most providers.
🔹 Interest on your money? They keep it. “Host Blues may retain interest earned on funds held in variance accounts.”
These are not a theoretical problems. These are not “Chris Deacon making shit up” problems. These are YOUR problems – if you’re using any BCBS licensee.
How can you:
• understand how plan assets are used
• monitor service provider compensation
• ensure fees are reasonable
• ensure claims are paid according to plan terms
if these are the terms by which you’re playing
Print this. Save it. Share it. Distribute it.
Send it to your BCBS rep.
This isn’t anti-BCBS rhetoric.
This is what the contract actually said – across the Blue Cross Blue Shield Association system. If it has changed and my concerns are moot… I challenge anyone to show me an updated “Inter-plan Arrangement Schedule” that addresses these concerns.
HOMEWORK READING ASSIGNMENT – Wanna A Peek At A Blue Cross Hospital Contract?
Check this out. See anything in it you don’t like? The district’s consultant liked it. The Superintendent liked it. The Board of Trustees liked it. QUESTION TO ALL: Did you read it? ANSWER: Yes, of course we did!………….Then why did you sign it?
