putting coin in piggybank

Summary: Insurance companies argue with health-care providers all the time over reimbursement rates. But it seems that lately the arguments are louder and more bitter, and that patients are taking the hit. Here are three separate instances from the last few days. The theme is generally this: It’s the other guy who’s at fault.



“CORPUS CHRISTI (Kiii News) – A war of words between Christus Spohn Health Systems and one of the state’s biggest medical insurance companies could end up costing you as a patient.

“Negotiators for Christus Spohn and Blue Cross Blue Shield of Texas are at an impasse over talks for a new contract set to go into effect when the old agreement expires on April 1. The contract determines the rate of reimbursement for services provided by Christus Spohn to Blue Cross Blue Shield members.

“The insurance company wants Christus Spohn to cute its rates by 20-percent, while the hospital wants a reimbursement increase of one half of one-percent. A negotiator for the non-profit hospital chain said this is the first time in 50 years that they have been unable to come to an agreement.” via Christus Spohn Reaches Impasse in Negotiations with Blue Cross B – KiiiTV.com South Texas, Corpus Christi, Coastal Bend.

And, in New Jersey, a similar theme

Also in New Jersey, Horizon Blue Cross has commissioned a study challenging out-of-network payment rules. Not surprisingly, that study, paid for by Blue Cross and written by Avalere Health, paints the providers as the evildoers, not the insurers. Andrew Kitchenman of NJ Spotlight writes:

“Horizon Blue Cross Blue Shield of New Jersey members could see significant savings in their insurance premiums if the state reined in the charges from some hospitals and healthcare providers outside of the insurer’s network, the company said this week.

“And a new Horizon-commissioned analysis lays out a series of policy actions that the state could pursue to make that happen.

“Avalere Health LLC suggested that the state could lower out-of-network costs by setting benchmarks to determine payments for healthcare services, or by requiring providers and insurers to settle payment differences through arbitration.

“The analysis cites a separate Horizon-commissioned study that found that if, instead of paying what it pays now for out-of-network services, Horizon instead paid 50 percent more than what Medicare pays for these services, the company would be able to cut its out-of-network costs by 52 percent, or $497 million in 2013 alone. That equals 4.3 percent of the total amount of claims paid through Horizon’s commercial insurance plans.

“Insurers and providers have been wrangling over out-of-network fees since last fall, when legislators held on ways to reduce out-of-network fees.

“Under state law, New Jersey insurers must pay for coverage of emergency visits, including ambulances, which are outside of a patient’s insurance network. They must also cover higher charges for specialists who are outside of an insurance network but work in hospitals that are inside an insurance network.

“This has contributed to some hospitals and providers charging high out-of-network fees – in fact, New Jersey hospital charges are the highest in the country.”

In Atlanta, hospital and insurer spar


In Atlanta, Grady Health Systems and Blue Cross and Blue Shield of Georgia are in a similar dispute. Kristina Torres of The Atlanta Journal-Constitution wrote:

“Senate Democrats took aim Monday at health insurance powerhouse Blue Cross and Blue Shield of Georgia, as they denounced the company as being more focused on profit than people in its financial standoff with Grady Health System.

“ ‘I don’t want one service at Grady to be paid at a lower rate than other hospitals,’ state Sen. Vincent Fort, D-Atlanta said on the chamber floor. ‘Blue Cross/Blue Shield needs to have a plan and a strategy to treat Grady fairly.’

“The statement came after representatives of the insurance giant visited the chamber’s minority party during an early morning caucus meeting.

“The dispute between Grady and Blue Cross began more than two months ago, after nearly a year of contract renewal talks broke off and a coverage agreement between the two expired. Thousands of Blue Cross customers who currently use Grady Memorial Hospital are being charged ‘out of network’ prices.”




Jeanne Pinder

Jeanne Pinder  is the founder and CEO of ClearHealthCosts. She worked at The New York Times for almost 25 years as a reporter, editor and human resources executive, then volunteered for a buyout and founded...