[Music]
DAN: Health care management companies,
venture capitalists, and third parties are
targeting some struggling rural hospitals.
They're using
a scheme called pass-through billing
to make hospitals more money but what does it mean for
the price of healthcare? Thanks for joining us today
for this edition of Blue Promise.
I'm Dr. Dan McCoy and I'm the president of
Blue Cross and Blue Shield of Texas.
I'm here with my cohost Ross Blackstone.
ROSS: Thank you Dr. McCoy and we have Rick Haddock
and Diane Carr, they're both part of
our network management team at Blue Cross and Blue
Shield of Texas. So guys it sounds like
there are some businesses that are really exploiting
hospitals and rural communities across Texas.
What's this about?
What's happening?
What is pass-through billing?
DIANNE: That's a great question Ross. So
pass-through billing is when you have a hospital
who's performing tests and the member has never set
foot in that hospital, they may not even know
of that hospital but their testing is being
run through that hospital so they're a non-patient.
What we call a non-patient.
DAN: So Dianne walk me through an example.
DIANNE: Absolutely so in some sense
your situation which you may see is a member
in the Dallas area will have the lab who performs
a test but the actual billing is sent to a
rural hospital in West Texas.
DAN: So if I'm.. if I'm the patient right
and so I go to a lab in Dallas and I got
my lab results back from my local doctor
would the bill say West Texas on it?
DIANNE: Yes in several instances there will be
several hospitals referenced on the
paperwork that the member will see.
RICK: And Dan that's a key identifier that
the members need to pay attention to,
is they need to look at the explanation
of benefits and if they see that
they had a service performed by a particular provider
but then they get a bill from a different provider
it should raise a red flag because the member obviously
knows that if the service was performed in Dallas
that there's no way that the member actually was also
in West Texas at the same time
getting that service performed.
DAN: Okay so I go to my doctor in Dallas
and I get ordered a test. I go to the lab,
but getting my results my doctor gets results
I get my care delivered and then a few weeks later
I get a bill from West Texas and it's sent to my
insurance company and it's covered under my benefits.
No offense but, why do I care?
DIANNE: Well you care because we as a company
for our members are paying more
for that service and in turn that that cost
gets passed down to our employer groups
and down to the members themselves.
DAN: So this is a scheme. An organized scheme to generate
higher costs for services that should be lower
because of those negotiated rates in Dallas.
DIANNE: Correct so a contracted hospital
a great example would be
a contracted hospital has set rates.
A contracted lab, freestanding lab
has set rates so if I'm a member and
my doctor is going to order testing for
me my first question primary question should be what
tests are you ordering because we frequently also
see extensive testing that may not be necessary so
that'd be my first question is
what tests are you ordering?
Where are you sending me to?
And can I go to someplace else?
Because we can call you can call the number
on the back of a card right and you can
ask for a contracted lab.
If you put numbers to that
those tests performed by a contracted lab
freestanding for one year would be
about three hundred thousand dollars.
The same tests run through one of our rural
hospital contracts comes to over a million dollars.
DAN: Wow so almost three over three times more...
DIANNE: Absolutely.
DAN: ...in overall cost.
DIANNE: Right.
RICK: Dan, what we're seeing is that this type of
billing practice there's there's a lot of
entrepreneurs in the healthcare industry
most some of them work for good but there's also some
that are out there that are for evil
and so what ends up happening is
as they look for revenue, enhancements, opportunities,
what they're gonna do is target those entities that
could benefit most from developing and deploying
something similar to what what's happening under
pass-through billing to where they can get revenue
and it gets harder and harder for
insurance companies unless you've got the capabilities
like Blue Cross does to be able to identify these
and put the appropriate processes and policies
and procedures in place to try to mitigate it
from happening in the future.
ROSS: So it's the labs …
just to make sure I understand, it's the labs
that are trying to optimize their revenue.
Why do the hospitals even get involved?
DIANNE: Well because of the hospitals are usually
struggling financially so when they're
approached by these companies its pitched to them
that this can help you stay open
this can help you remain in that community
and by doing that they kind of throw them a
lifeline right?
The hospital is you know is struggling.
They have nothing to lose, so they engage in this
situation where a cut of it will go to that
marketing company and a cut will go to the hospital
and a cut will go to the labs.
RICK: Yes so Ross most of the time hospitals
they don't make their money on outpatient services
like lab that's usually a commoditized
service that is a very small piece of
their total revenue.
What happens in these outlying markets
where you don't have a lot of acute care admissions
where patients go to the hospital when they're
really sick and they get admitted to the hospital
they utilize the outpatient services so these
hospitals have figured out a way through these other
third-party companies where they take these
commoditized services that are much more expensive at
a hospital than in a non- hospital setting and try
to drive volume to allow that hospital to be
able to bill for those services so that hospital
can generate additional revenue that they
otherwise wouldn't have.
ROSS: So the hospitals have a bargaining chip
because they had… they get a higher
reimbursement rate than the lab.
How much higher are we talking?
RICK: Almost four times.
ROSS: Four times more.
DAN: So basically that's four times increase the cost
but in reality for no improvement in quality
or anything.
DIANNE: Correct.
DAN: In fact it's just a sham bill
DIANNE: Absolutely… absolutely because that member
is never seen at that hospital. The member,
you know, has probably never heard of
that hospital.
DAN: Okay so back to my example
So if that were to happen to me and let's say that
I wanted to be a stalwart and I wanted to make sure
that this didn't happen how would I tell?
What's the indication to me as a patient that
this scheme is going on?
DIANNE: So in some instances what's happened
is members have received those
explanation of benefits and it stated
that your testing was done at a hospital
in West Texas and we've had them call our lines
and say you know I don't know this hospital.
I've never heard of them what happened here?
That's someone who's really, really paying
attention to their care and to their explanation
of benefits and when they call us that's great
because then that helps us address that situation
because that's what we want to do.
We want to keep the rural hospitals open
but we want to do it appropriately and
provide you know value-based care for
our members.
DAN: Gotcha.
ROSS: I think if I could just to your question
Dr. McCoy we do have a fraud hotline that our
members can call so I'd like to just share that number
It's 1-800-543-0867. 1-800-543-0867.
We also have a section explaining this whole
pass-through billing concept on the provider section
of our website if people wanted to get
more information so there are things that our members
can do because ultimately it does
affect them because you know they might get
the bill..
the care might be covered but at the end of the day
it's driving up everybody's costs.
RICK: Yeah and Ross one thing I did want to note too
it's not unique to Blue Cross we're not only seeing
this in the state of Texas but it's happening n
nationally and in fact there was an expose that
recently was aired on CBS News during primetime
that talked exactly about this topic it talked about
lab pass-through billing and the schemes that were
occurring around the country.
DAN: So in reality it's not..
I'm gonna make sure we're clear that
we've used a term pass- through billing but it's not
simply passing through billing right?
It's stacking on additional cost on top of the bill.
There's a reason why it's being passed-through and
the only reason really is to generate bigger revenue.
Is this a new problem?
DIANNE: No absolutely not this has been going on
for years.
I think what's happening is as more rural hospitals
are struggling and the marketing company
is becoming more aggressive,
I think that's how it's happening.
They've become very savvy and in terms of looking
at local news reports you know a lot of these
rural hospitals will be in their local news
about their situation.
I think a lot of it is the hospital have nothing
to lose when that person walks in the door
and says hey I can make you a million dollars in a year,
they seize on that.
DAN: Okay so I'm gonna kind of…
I'm gonna stretch a little bit.
So that you said lab and when most patients think
of lab they think a blood test so it's a blood test.
Is it limited to just that or pathology included?
And other kinds of expenses that might occur?
DIANNE It's.. so for labs it's generally it can
be blood draws, it can be urine screens,
those types of items for labs.
RICK: But we're also seeing it spread to
other service lines as well, Dan.
We're seeing it where we've got some entities
that are pass-through billing sleep services
when they're not providing the sleep study themselves
and so what we're trying what we're starting to
identify is that it started with lab but now it's
starting to expand into other service lines as well
and so at least at Blue Cross we've got a keen eye
on making sure that we're watching all outpatient
services and how facilities around the entire state
not just isolated to rural areas but how they're
handling and billing for services and what we do
is we look for spikes in billing patterns so that
if all of a sudden you saw that you were paying
a hospital over the last 12 months you were
paying $500,000 for a particular service and
then it spikes to 12 million dollars
then that's obviously a red flag that lets you know
that something's going on and it's not just an
increase in the volume that's related to…
isolated to the market that they're in that
there's something else underlying that's pervasive
that's occurring that we need to address and
look into to.
DAN: Let's make clear so that I think there's…
what you're also saying is is that we're appropriately
paying the provider that performs the service
that's okay right so for rural hospitals doing a
lab work they should get reimbursed for it but
what you're basically saying is if somebody
else is doing it
you can't just use this scheme to make the bill
a lot higher for the consumer.
DIANNE: Absolutely and that's kind of what we're
doing here at Blue Cross Blue Shield
is our goal is to appropriately reimburse
those providers and to kind of…
this is completely against... it's completely against our
policies and procedures so our goal is to make it a
less attractive situation for those providers.
RICK: And it's no different than any other industry
where I'm not aware of where an individual
who doesn't provide a service can actually
get paid.
Usually you provide a service and you get paid.
In this particular case what's happening is they're
not providing a service but they're getting paid and
they're doing it in an illegitimate way.
DAN: Okay so Dianne let me ask you a question,
Is this fraud?
DIANNE: Well I think we have to look at that
in a case-by-case basis in some instances absolutely,
ROSS: You mentioned case-by-case
I have a graphic that I pull from some of the
research that you guys sent us
Dr. McCoy.. this these red boxes are these these
businesses in these labs that are sending lab tests
to all these blue hospitals and look at…
I mean look
it's a complicated web you know So Rick when you talk
about finding spikes it's not like it's just
you just go and find
one there are things are interconnected it's hard to
tell because there might be you know sharing of services
and sharing of expenses and this is really complicated.
RICK: It is and it started with hospitals but there
again it's…
I call it predatory in nature
that these third party companies are also looking
at other institutions beyond just your
acute care rural hospital to try to have
a very similar scheme for either the same or different
services where that entity doesn't provide the service
but they bill for it because it's just a way to
maximize revenue.
DAN: Well Dianne,
Rick I've learned a lot about
pass-through billing and I've learned what as
consumers what you need to be on the lookout
for, so thanks for being here and thanks for joining us
for this episode of Blue Promise.
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