Transparency In Healthcare


“This is as clear as I can make it, if you work with one of the big healthcare carrier (ASO) companies there is no transparency and there never will be.  “ – Mike Dendy

Michael (Mike) Dendy

CEO/Vice Chairman AMPS Inc.

I have seen the words transparency and healthcare coupled together too many times today to let it pass without comment.  This is as clear as I can make it, if you work with one of the big healthcare carrier (ASO) companies there is no transparency and there never will be.  You have a better chance of seeing through a brick wall than understanding what you are paying for healthcare services within their PPO networks.

The reason is that the opacity of their services completely covers the lack of quality and positive outcomes that they pretend to provide.  If your company is paying for hospital services via a PPO network you have contracted to overpay by as much as 30% on average and often much more than that.

Further, the ASO/carriers don’t review your hospital claims before they pay them.  How about that relative to your $20 to $50 PE/PM admin fees?  ASO/Carriers ask for nothing more than a uniform bill (UB) as evidence of what was performed on your employee/member during a visit.  They take the UB, most often a singular piece of paper with no significant detail, and write checks to their hospital partners with your money.  Keep in mind, this is the company with whom you share fiduciary responsibility to protect your plans co-mingled assets.  I had a health insurance carrier tell me, several brokers, and a client on a conference call not too long ago that “they would not bother their partners (the hospitals) by asking them for details on hospital invoices prior to payment”.

Now, sometimes the carriers/ASOs audit their work after the fact, most times many months or years later.  Ah, that will get your money back…but, not so fast, there are a couple of hitches.  First, if they do audit and find out that THEY MADE A PAYMENT ERROR WHEN FIRST ADJUDICATING YOUR CLAIM THEY RETURN ABOUT 60% OF YOUR MONEY AND KEEP THE REST FOR DOING THE AUDIT…. WHERE THEY UNCOVER THEIR OWN MISTAKE.  Truly, this is healthcare in the U.S.  Anything goes..  Now, the bad news.  Most carrier contracts allow them to keepall of your money if you are no longer an active client.  Check your carrier contract, it’s in there.  Sounds like a profit center opportunity for the carriers to me. The more mistakes they make, the greater their bonus when they audit.

I know what you are thinking, this could not be your ASO/Carrier.  They consider you a preferred client and you get lots of extra attention and reporting and such for being so.  So, prove it to yourself and call your health insurance rep right now and ask for the following:

  1. Ask for the detail bill or itemized statement (same thing) plus the medical records on the 10 largest claims paid on your company’s behalf in the last 12 months.  I don’t mean to ruin the surprise but, they won’t have the data.  Ask yourself why your 10 largest claims would have received no scrutiny whatsoever before your payer partner wrote a check off of your bank account.
  2. Ask that your carrier ASO benchmark the 50 largest claims paid on your behalf in the last 12 months.  You want to know, what the medical provider’s gross billing was and what the net payable post PPO discount was relative to what Medicare would have paid.  Sorry again, no surprise here.. they won’t give you the answers you want.  They will say that such data is proprietary.
  3. You CAN get the answer to the last question.  Pull out your carrier/ASO contract and check for yourself on the language around their audits of their own payment mistakes.  Have a garbage can handy for your reaction.

Enough about transparency in healthcare.  Unless you have an independent TPA administrator that is not beholden to a carrier’s PPO, there is no transparency for you.