| I |
Goal : Return to Top : Exit Article |
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| A. |
Control Health Benefit Costs |
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| 1. |
Cost Shifting |
| 2. |
Controlling Costs |
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| II |
Tools : Return to Top : Exit Article |
| |
| A. |
Health Benefit Plan (Insured
or Self-Insured) and ERISA law. |
| |
| 1. |
Claim via ERISA Assignment |
| 2. |
Defend Claim Against The Worker |
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| III |
Limitations On
Doctors' Charges : Return to Top : Exit Article |
| |
| A. |
Reasonable and Customary |
| |
| 1. |
Reasonable: Excess Income |
| 2. |
Customary: What The Doctor Charges
Other Patients |
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| B. |
Prevailing |
| |
| 1. |
CPT (Current Procedure Terminology)
Code |
| 2. |
75th, 80th, 90th Percentile |
|
| C. |
Other |
| |
| 1. |
Misidentified or Unbundling of CPT
Codes |
| 2. |
Fraud |
| 3. |
Unnecessary Care |
| 4. |
Price Fixing |
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| IV |
Limitations On
Hospital Charges : Return to Top : Exit Article |
| |
| A. |
Reasonable and Customary |
| |
| 1. |
Charge vs. Cost |
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|
| 2. |
What The Hospital Collects From Other
Payors |
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| B. |
Inaccurate Charges |
| C. |
Other |
| |
| 1. |
Unnecessary Care |
| 2. |
Price Fixing |
|
| D. |
Hill-Burton Act |
| E. |
Declaratory Judgment (Credit
Bureau Attack) |
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| V |
Doctors' Charges : Return to Top : Exit Article |
| |
| A.. |
Price By CPT Code |
| B. |
Discounts For Medicare, Blue
Shield, PPO's, HMO's |
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| VI |
Hospital Charges : Return to Top : Exit Article |
| |
| A. |
Target Income Pricing Based On
Percentage Increases |
| B. |
No Relation To Cost |
| C. |
Different Departments Have
Different Cost To Charge Ratios |
| D. |
Discounts For Medicare, Blue
Cross, PPO's, HMO's (Contractual Adjustments) |
| E. |
Profits Even For Non-Profit
Hospital |
| |
| 1. |
Build Empire |
| 2. |
Nest Egg For Rainy Day |
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| VII |
Challenging
Doctor's Charges : Return to Top : Exit Article |
| |
| A. |
Draft Health Benefit Plan To
Allow Challenge |
| |
| 1. |
To Define |
| |
| a. |
Prevailing: 80th/9Oth
Percentile and HIAA Data |
| b. |
Customary: Lowest
Non-Hardship Charge |
| c. |
Reasonable: Not To Exceed
$200 Per Hour |
| d. |
Use of CPT Code |
|
| 2. |
Administrator Has Discretion To Make
Final Binding Decision |
| 3. |
Insurer Administrated, but
Self-Insured Avoids Mandated Benefits:
Limit |
| |
| a. |
Psychiatric |
| b. |
Chiropractic |
| c. |
Other Problem Areas |
|
|
| B. |
Create PPO or Use Managed Care
Contract And Obtain Discounts |
| |
| 1. |
Trade Association/Employee Groups |
|
| C. |
Investigate Accuracy Of CPT
Coding |
| |
|
| D. |
Unnecessary Care |
| |
|
| E. |
Check For Fraud |
| |
| 1. |
Employee Review of Bill and
Certification |
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| VIII |
Challenging
Hospital Charges : Return to Top : Exit Article |
| |
| A. |
Obtain Medicare Cost Report
Under Freedom Of Information Act |
| B. |
Obtain IRS Form 990 For
Non-profit Hospitals |
| C. |
Obtain PPO, HMO, etc.,
Contracts In Negotiations or Litigation |
| D. |
Limit Payment To Cost Plus
Reasonable Profit |
| |
| 1. |
Draft Health Benefit Plan To So Limit
Reimbursement |
| 2. |
Challenge Under Workers' Compensation
Law |
|
| E. |
Create PPO or Use Managed Care
Contract For Discount or Fixed Costs |
| F. |
Utilization Review |
| G. |
Accuracy Review |
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