Lots of activity in the Sutter/Blue Shield pi$$ing match.
January 20th, Sutter give press release.
To which BS responds…
And BS issues their own press release: http://pages.blueshieldca.com/dK0HQ1xBah0Yu00X55010J0
So, BS has offered to extend their existing contract with Sutter. Sutter however want the right to unlimited price increases during the contract time as well as limit patient (and BS) legal recourse. Sound to me like Sutter is the bad boy in this situation.
Having gobbled up medical practices and hospitals in an attempt to gain a monopoly and raise prices, Sutter is afraid of anti-trust litigation. They want Blue Shield to agree that Blue Shield and their customers can’t sue Sutter. Blue Shield isn’t going for that.
Sutter’s plan is, “Write us a blank check and promise not to sue, and we have a deal!”
That’s it in a nutshell…weird world when the health insurance company is the good guy.
In the ACA world where insurance companies are fighting for your business based on price, not on whether you are healthy, the insurance companies are on your side as far as wanting lower cost services.
Don’t be so sure they will – it wouldn’t surprise me at all if your agent is being given misinformation by a Blue Shield rep, and that if you actually submitted an application that way that there would be some hitch down the line.
Worst case scenario would be if they sold you the insurance and then later cancelled your policy when you had a big claim, based on an assertion that your enrollment was fraudulent.
^^ I’m not sure what to make of the whole thing. I don’t see how it could be fraudulent if they accept us as a group if we provide all the info correctly. Maybe on-exchange (SHOP) the rules differ from off exchange. But it’s all angels dancing on the head of a pin at this point. Not making any changes or moves until mid year at the earliest.
D - the budding tax CPA - recently attended an update seminar. She said they spent more than half the day discussing ACA issues. The presenter stated they are seeing more and more individuals simply accepting the penalty. They are seeing more address fudging. Also the attendees were told to expect an increase in billable hours to each account because the additional ACA related information and forms were very time consuming. And, that at this point nobody really knows what the IRS is going to do.
Blue Shield and Sutter have reached a new 2 year agreement…
Seems like you drank the Blue Shield cool aid.
I’ve been told that BS DECREASED their prices paid to Sutter while INCREASED their prices to their customers. Why did they tell their customers that Sutter was in the network during enrollment period knowing fully that a huge impasse is looming.
Not sure how posting a press release relates to drinking either sides’ Kool Aide…but…
Sutter’s prices are the highest out there. In short, I personally have compared their negotiated fees to those of other practices in my area and have found Sutter’s to be up to 4X (that’s FOUR TIMES) higher than other practitioners. That is…Sutter has negotiated a price that is 4X higher,m and that what BS then pays. Sutter wanted yet another increase this year. Not sure what is in the new contract (Sutter’s insists on gag clauses ). but if BS was able to get a reduced fee structure GOOD FOR THEM! There is not reason a simple in office procedure should cost a patient $360 while the same procedure at a different in network provider costs the patient $90.
Not sure if Sutter is only afraid of anti-trust litigation…but they wanted BS to agree to a clause which prevented customers or BS from suing.
Why am I not surprised?
I’m almost disappointed that I won’t have the opportunity to check out Kaiser. :-S
(I do prefer some continuity in care if possible… but I definitely was going to change coverage if they didn’t have a resolution by early Feb. I guess they figured out that there would be others thinking along the same lines).
Out of curiosity, dietz, you compared identical billing codes, right?
How are you able to do that? You have to compare different policies of identical coverages. It’s almost impossible to find out.
Sometimes a less expensive policy will have higher negotiated prices so the patient is left paying a higher amount. A healthy adult will be able to buy a less expensive policy but pay a higher price if service is needed. Different tiers of coverages will have different negotiated prices. Providers bill the same with the coding but the insurance company decides how much of the billing gets taken off.But not all providers are transparent with the original billing and not all policies within the Blue Shield family have the same negotiated price with the same provider.
In addition, charges for an identical procedure are also dependent on who you see. For example, freezing a skin lesion will be charged $x by a general physician, the same procedure will be charged $3x if done by a dermatologist and $5x by a plastic surgeon.
How do I know this?
Too many phone calls to insurance companies and billing departments for coding errors and payment disputes !!
I have the same experience as Dietz – same services, within a year, same insurance company.
My local doctor was on Blue Shield prior to ACA, but she did not sign onto the ACA plans. However, her office staff was not able to inform me that she was no longer in-network until March, and I had an urgent situation and ended up seeing her in January.
So I have records of bills and EOB’s from Dr. A. in 2013, pre-ACA; bills from Dr. A. in 2014, post-ACA (when the doctor was paid “usual & customary rate” – and records of EOB’s from Sutter post-ACA. Sutter’s rates are indeed roughly triple what the other doctor was paid-- and Dr. A. actually got paid slightly more when she was “off network” than she had receive for similar on-network services the previous year.
However, I do feel like I am getting better quality of care from Sutter than I received from my former doctor.
Here is what I did…
I found that Sutter was in this case 4X higher than the other providers charger rate! (I’d get a 33% discount from the others in addition to a much lower base charge)
I found that the Medical reimbursement rate for our county was between $37-$42 dollars for my $360 Sutter procedure.
I found out that Sutter would charge H $3750 for the room for his colonoscopy. The same doctor would perform the procedure at the non Sutter surgery center down the street and the negotiated rate for the room would be $1100. This was before ACA mandated preventative care. And, Sutter hemmed, hawed and dawdled on providing the info until I cited the CA regulation which required them to do so.
They are a horrible horrible horrible company. Non-profit my arse.
@Calmom: My experiences were pre ACA.
@dietz199
Why didn’t your insurance pay? I never pay full EOB.
Was $3750 your negotiated rate? Sutter doctors perform colonoscopy at Sutter Surgery center and nowhere else.Very rarely do non-Sutter doctors perform colonoscopy at Sutter. Were you seeing a Sutter doctor?
What procedure was that? Seems really low, what can you get done for $42 reimbursement medically or non-medically?
In view of this, are you still seeing Sutter doctors? I am saying this because you said you have several Sutter doctor friends.
The point is that Sutter’s negotiated rate with the insurers is significantly higher than what other providers get.
The just-ended Sutter/Blue Shield standoff is an illustration of the reasons. Neither entity can survive without the other - but this time around they both dug in their heels and waited to see which would blink first.