“What would your plan have paid for these claims?” asked the plan sponsor shopping for competitive alternatives.
The group is insured by a BUCA in Texas. The totals shown are PAID AMOUNTS not ALLOWED AMOUNTS:
CLAIM #1
Primary DX Code: J386
Primary DX Description: Stenosis of Larynx
Primary Procedure Code: 31622
Primary Procedure Code Description: Bronchoscopy; diagnostic (flexible or rigid) with or without cell washing or brushing
Total: $161,850.79
CLAIM #2
Primary DX Code: K811
Primary DX Description: Chronic Cholecystitis
Primary Procedure Code: 47562
Primary Procedure Code Description: Laparoscopy, Surgical; Cholecystectomy
Total: $38,061.09
CLAIM #3
Primary DX Code: N471
Primary DX Description: Phimosis
Primary Procedure Code: 54300
Primary Procedure Code Description: Plastic Operation of penis for straightening of chordee (EG, Hypospadias) with or without mobilization of urethra
Total: $64,463.94
CLAIM #4
Primary DX Code: Z1211
Primary DX Description: Encounter for screening for malignant neoplasm of colon
Primary Procedure Code: 45385
Primary Procedure Code Description: Colonoscopy, flexible, proximal to splenic flexure; with removal of Tumor(s), Polyp(s), or other Lesion(s) by snare technique
Total: $77,810.74
You might be asking “Why are these claims so high?” Here’s a possible explanation:
The Affordable Care Act (ACA) requires health insurance companies to spend a minimum of 85% of premiums received on medical care. That means a health insurance issuer cannot earn more than 15%. The only way to make more profits is to pay more for claims. The higher the claims are paid, the greater 15% equals. Therefore, insurance companies have absolutely no incentive to reduce claim costs and every incentive to increase them.
