How Much Would Your Plan Pay For These Claims?

“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:


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


Primary DX Code: K811

Primary DX Description: Chronic Cholecystitis

Primary Procedure Code: 47562

Primary Procedure Code Description: Laparoscopy, Surgical; Cholecystectomy

Total: $38,061.09


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


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.