Credit: Andrey Popov/Adobe Stock
The claim administrators serving some employer-sponsored health plans have come up with a sneaky cost-cutting strategy: They intentionally pay a doctor or hospital the wrong reimbursement rate.
Craig Gottwals, a veteran benefits consultant, talks about the stealth claim discounting strategy in a recent Substack commentary.
An employer plan that uses the strategy may rent access to a national provider network and agree to pay the network providers a typical reimbursement rate, such as 254% of what the traditional Medicare program would pay the provider, Gottwals writes.
Instead, an outside claim services vendor takes the claim, applies its own repricing rules, and then pays the claim.
A sneaky claim services vendor typically pays an amount equal to just 100% of what the traditional program would pay, Gottwals says.
"Medical claims are processes in massive batches of tens of thousands, and the provider or facility's largest customer, by volume, is Medicare," he says. "Unless someone is manually reconciling payer IDs, rate tables and logos (and, let's be honest, they usually aren't), this stealth claim slides right through."
If the provider does notice, the plan may simply apologize for the "error" and pay the correct amount, Gottwals says.
Meanwhile, Gottwals says, some frustrated providers have hired "revenue bounty hunters" who use artificial intelligence systems to look for underpayments. The firms then help the providers try to collect the missing payments.
The thinking: Gottwals wants to help employer plans get away from the current cost-cutting strategies and move toward more transparent, "reference-based" pricing systems, or efforts by an employer plan to ask health care providers to supply a service for a clearly stated price that the plan is willing and able to pay.
The backdrop: Gottwals sees the current opaque, aggressive plan and provider strategies leading to what amounts to an unsustainable shadow war.
Related: Employer group asks IRS to save health plans from surprise medical bills
In recent months, frustrated health insurers and health plan administrators have sued providers over their billing strategies.
Frustrated providers have sued the plans and plan administrators over their payment strategies.
© Arc, All Rights Reserved. Request academic re-use from www.copyright.com. All other uses, submit a request to TMSalesOperations@arc-network.com. For more information visit Asset & Logo Licensing.