Independently Investigating Healthcare Costs and Quality to Improve the Business of Healthcare
Would you pay a bill for $24,500 without looking at what you bought? Your insurance carrier does every minute with your company's money. Let's say you are at a restaurant and the waiter brings a bill for $1,071 and you expected maybe $300. However, instead of the bill in this picture, your bill only has the total. Are you suspicious? Do you ask to see the itemized bill? In healthcare, the bill you normally see is the 'UB-04'. The UB-04 does not show the itemized costs. It is a bill where you mostly only see the total. The real detail is in the itemized statement. That is where you can see if you are being taken to the cleaners. If this is a dinner bill, it is probably correct. If this is a hospital bill, it is unfortunately almost for-sure not accurate, and unfortunately those bills are tens of thousands of dollars. Next time you talk to your carrier, ask two questions: (1) For what size of bills do you require do you require itemized statements? (2) What percentage of claims, above 10K, do you auto-adjudicate? Now you know you have a problem. That is the number of HUGE bills that your carrier is paying, with your money, only looking at the total for the bill. You don't have to be a healthcare expert to guess this is a HORRIBLE idea. If you are a healthcare expert, you KNOW this is a horrible idea. You need someone looking at these bills. We can look at these, at no cost unless we find savings. Others also offer these services. Just makes sure SOMEONE is looing at these . . . because your carrier is not. #claimsintegrity #employeebenefits #brokenhealthcare
Using a TPA in a self-funded plan is kinda like giving your teenager your credit card with a $60k limit to go buy your groceries and whatever else he thinks you might need indefinitely...you might want to keep an eye on that...🤑 👀
Anju Sikka
2w
If you have never worked for Network Contracting or never had the opportunity to be close to it. It’s beyond your imagination how creative it is, who gets paid what, who is the sucker, what u see in public domain is no where close to the reality. To get to the bottom if this SCUM, some daring folks will have to take a deep dive. It will be a lot of very painful work.
So don't private medical insurers agree the costs of the required treatment upfront?
I have always disputed the bills from hospitals and requested itemized bills... I also requested an explanation of some of the items which the hospital never seemed to be able to explain. Taylor Davis MS Stat MBA what do you all do and who is it for? your website confused me (it may be me and I get easily confused)
Understand the sentiment but this is on the hospitals and medical providers for overcharging and hiding charges. The insurance carriers "trust" them do be honest. I agree you should always get a detail bill regardless of what they want to provide otherwise dispute the bill until they provide it.
Totally. Also, can I come to dinner next time?
Omg, a UB-04 is itemized!
Ellen Brown
3w
Couldn't agree more.
And if my “insurance is paying for it” then you might as well get a steak!!!
Vice President of Operations and Compliance Programs
2wPayers use sophisticated AI tools today to review claims as they come in and have robust payment integrity teams that request detailed chart notes to review the appropriateness of payments on a prepay and postpay basis. They also invest significant dollars in prepay and postpay quality audits to ensure Group's premiums are being used effectively. There are performance guarantees in place to ensure claims are paid accurately and timely. One of my teams has audited over 65k claims on a prepay basis to date. Being good stewards of our Group's premiums is a critical part of our job.