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posted: 10/16/2013 4:40 AM

A burning question about health care

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A burning question about health care

I have a burning question that has gone unanswered since I picked up my insurance broker's license in 2002 until I could figure out how to build my project management practice. Maybe someone who is willing to answer the question(s) would actually step up and give the answer(s); I'll take one or both, and here they are:

When calculating the 80/20 portion of the PPACA (aka Obamacare); do the insurance companies use the amount of the money they send to the providers after the "in-network" discount or the amount of the bill sent to them (i.e. list price) from those providers?

Example: hospital bill is $100,000 but they get paid $60,000 by the insurance company. Does the insurance company count the $100,000 as the "value of services" as written in the ACA?

This was how they used to calculate your 'lifetime maximum benefits' when there were limits on them and I am presuming they're using the same accounting practice to count toward their 80/20 for individuals and 85/15 for groups.

Second part: when counting their 2 percent of services given to the indigent; do the providers count the "in-network" discount (i.e. amount reduced) as part of their operational cost so they can raise the list price "up to" 10% as provided in the current laws?

Same Example: If the hospital receives $60,000 for the $100,000 bill; do they count the $100,000 as their operating expenses that goes toward their not-for-profit status?

This has been double-dipping the industry for the past 30 years and that's one of the main reasons why our health care costs so much.

I look forward to your response.

Walter F. Stanton


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