|
|
 |
|
Services
|
| |
For the self insured
|
| |
How Overcharges Happen |
| |
Most TPAs process hospital charges from an abridged bill called the UB-92. These hospital bills contain no itemization of services, procedures or supplies, only summaries by department, such as Pharmacy: $12,567.92, or Non-Sterile Supplies: $7568.77. This summary does not reveal the names of medications, quantities used, or the number of units required. Using this method of processing claims, there is no way to ascertain the accuracy or veracity of charges; inaccuracies are also processed through.
The American Medical Association and CMS have agreed to define many procedures as a package of supplies and facilities that are used routinely. If the hospital doesn’t follow correct coding principles, and many do not, these costs become part of the summary charges on the UB-92. These are the overcharges often levied on the uninsured, but turn up on everyone’s itemized bill.
Most corporations have entered into discount agreements with hospitals and other providers, but fail to know the base price. The provider may therefore be inflating charges, then giving what the payer thinks is a generous break on the price. We recently worked with a client whose TPA was processing claims that were over charged by close to 100%, but giving them a 60% discount. This company thought they were getting a great price cut when they were actually paying 40% more than they should have.
Some charges are simply invalid, as when payments are made on claims for employees or family members who are no longer with the firm or otherwise ineligible for coverage.
|
| |
<<Back
Next>>
|
| |
|
| |
 |
|
Copyright© 2004 Health Plan Navigator LLC All Rights Reserved |
|
