For many self-insured employers, it can be easier to plant-head-firmly-in-ground than confront the problem of claims data overload
It’s easy to get overwhelmed by the staggering amount of claims data available today. It’s also all too easy to index too far on the other end of the spectrum, deciding that you must process every data point to ensure that you don’t miss something important.
Finding a happy medium is key, whether you’re using a pricing intelligence (CI) platform like SurgeryShopper.com or not. One critical skill is learning to identify the less obvious signals that could have the most impact on savings for your claims trust fund and building process around utilizing providers who offer competitive bundled prices for surgery procedures.
We spoke with Maria Todd of AskMariaTodd™, an internationally-recognized healthcare business development expert with more than 3 decades of contracting with employers and health, travel assistance and workers comp insurers for bundled price surgeries around the USA and abroad. Here’s how she explained what’s happening in the marketplace.
Consolidation of hospitals
Many hospitals are consolidating which leaves consumers with fewer competing options. The consolidated hospital brands have the ability to increase and sustain higher prices in the marketplace for surgery.
Medicare is not as innovative as it claims
Medicare innovated bundled pricing for certain categories of surgeries. It then expanded the variety of cases that can safely and efficiently be performed in an ASC setting as an outpatient. But it forgot to change payment policies. So, as a result, hospitals get paid for knee implants and hip implants and screws and hardware needed to perform the procedure. ASCs don’t get paid for the same items for the same procedures. That means reference-based prices offered to hospitals are are inaccurate and higher than they need to be and too low or too high to offer similar rates to ASCs. Patients are at higher risk for hospital-acquired infections because there are more exposure sources in a larger hospital facility. That affects quality and outcomes.
Hospitals manipulate physician and surgeon supply and access to care
By buying up physician practices or forcing independent physicians out of business, they limit the public’s ability to get timely access to care, purchase at competitive prices and arrange surgery with independent surgeons they trust. 20% of consumers state that they cannot get appointments and that the doctors don’t have time to answer questions. 7% feel that their hospital-employed physicians prescribe unnecessary tests and procedures and don’t explain why the tests and procedures are necessary. 65% of patients surveyed say that they trust independent physicians more than hospital-employed physicians. (n = >3500). Of those, 53% are GenZ/Millennial and 75% are Baby Boomers.
TPAs have attempted to replace PPOs.
Don’t they get that those opaque middleman cost layers are history?
New contracts floating around hospitals and ASCs are the new “cut and paste ransom notes”. The TPAs are layering themselves in for a per-employee-per-month fee to debase the savings the providers are willing to offer. What gets shown to the employer is a vastly different number from what the provider is willing to accept and how much the provider is actually paid. And it’s all coming from the claims payment trust fund. Once the employer learns they’ve been duped by their TPA in this way or their broker, it’s game over! No city administrator can stand before the taxpayers and say, “As the plan fiduciary, I agreed to pay more than we should have for healthcare because our TPA and our broker of record or agent of record duped us and layered themselves in for hundreds of thousands of dollars in fees we didn’t know we were paying for.”
And the same goes for plan administrators and fiduciaries of corporate group health benefit plans. No plan administrator would be eager to say the same words to shareholders or employees who have been watching salary deductions take a chunk of money paycheck after paycheck and tell them, “we’ve been paying more than necessary out of the trust fund we set up to pay claims because our TPA or our broker of record or agent of record duped us and layered themselves in for hundreds of thousands of dollars in fees and trips to Vegas and Hawaii we didn’t know we were paying for.
5 Ways SurgeryShopper is different from other contracted provider networks
- First, and foremost, SurgeryShopper.com doesn’t represent the self-insured employers. It represents the providers in the USA who want to connect with and contract directly with employers.
- SurgeryShopper only lists surgical procedures all across the USA. Imaging and lab and other providers are not included in our database. There are many one-size-fits all networks in the marketplace. Instead, we focus on what we do best. We help providers to prepare for and transact business directly with the employer who has agreed to pay the bill and verify eligibility and coverage of the services being requested.
- Second, the SurgeryShopper.com providers don’t charge a per-employee-per-month network access fee. Nor does SurgeryShopper.com charge a network access fee.
- If you want a surgery we list, call us and arrange it. You don’t need a special card or an introduction from a broker or agent to use the system as a single case agreement or as a continued relationship. It only works when you have a surgery case requirement and a fiduciary requirement to conserve trust dollars and make good decisions about the providers approved to treat your plan participants.
- You don’t need a minimum number of cases in a year to take advantage of these rates. Just call or email us if you have a case and you are ready to save money. The only catch is this: Be ready to pay what you’ve agreed to in advance, or in accordance with the providers’ terms and conditions. They are accredited, credentialed, privileged, insured, inspected, and have their terms and conditions ready in a memorandum of understanding or a single case agreement or a full-blown contract. There’s no balance billing, no surprise billings, and no payment delays. If you want volume concessions, the providers want to see utilization first, not empty promises and hyperbolic claims of surgeries to come. Then, they may agree to sharpen their pencils for you. ♦