About Anthem Blue Cross Private Health Insurance Payments to Doctors....

Reader comment on: Anthem Blue Cross Premium Increase Irks Sebelius

Submitted by xzr56 (United States), Feb 26, 2010 14:43

Upset that your monthly Anthem Blue Cross Health Insurance Premium charges will increase by 39% in 2010 after 2009's 20% increase (in this time of "no inflation")? Just remember that Private Health Care Payments = Government Health Care Payments + 20%.

The "Maximum Benefit Allowance" for over 8000 procedures codes with private health care supplied by Anthem Blue Cross Blue Shield is the Medicare rate (ie: government single payer rate) plus 20%. That is Anthem's "Maximum Benefit Allowance" even if your private health insurance premiums are double or triple what you would pay into a government option.

You pay so much up front as a private investor owned health insurance policy holder, while medical providers who actually do the work on you get paid so little out the back door. Why should Anthem pay any more than 20% higher than government reimbursements? Doctors cannot negotiate with large health insurance companies. They simply take what the health plan offers as reimbursement, or they leave the health plan.

Private health insurance companies only need to pay out a little bit more than government reimbursement rates to claim the high ground of the "socialized medicine" hot button "debate". But then private health insurance companies work tirelessly to avoid payment, deny treatments, create unending confusion and complexity, increase paperwork for policyholders and providers, etc etc etc.. The great thing about this setup is that private health insurance companies can always shout out how they pay doctors MORE than government health insurance, but they never say exactly HOW MUCH MORE, even if you are paying monthly premiums that are double or triple than what you'd end up paying to the government to buy into medicare… A very large protion of the huge pile of money Americans pay to the health insurance industry is skimmed off as profit for wall street investors, and high salaries / bonuses for executives.

Here it is, straight from the horse's mouth.

(exact copy of text from my recent Anthem BCBS rejection of appeal letter requesting payment to a health care provider...

< <<<<<<<<<<<<

"Anthem's maximum benefit allowance (MBA) is based on a calculation. The calculation is determined
by multiplying a payment rate or unit value assigned for a particular service performed by a professional
(i.e., a physician) or hospital by a conversion factor. (Unit x Conversion Factor= MBA)

The Medicare "Physician Fee Schedule" establishes the payment policies and payment rates for over
8,000 procedures that are performed by physicians and by certain non-physician practitioners such as
nurse practitioners, physician assistants, and physical therapists. Payment rates or values are assigned for
a particular service, such as repair of a wound or lesion,drain/inject joint/bursa, reconstruct lower jaw
bone, etc. (Medicare: Relative Value Unit (RVU) x Conversion Factor = Medicare allowable)

To determine the payment rate for a particular service, Medicare applies a conversion factor expressed in
dollars. The same conversion factor applies to all services paid under the fee scheduled and is updated

Anthem applies its own conversion factor to determine the payment rate for a particular service.
Anthem's conversion factor is greater than Medicare's. As a result, Anthem's MBA is greater than
Medicare's allowance, and typically is between 1l5% and 120% of Medicare. The unit value used by Anthem is the same value determine by Medicare for its RVU.
Medicare's conversion factor : 37 .01
Anthem's conversion factor : 44.04 (@ 119% higher than Medicare)"

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Other reader comments on this item

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feb 28 bluecross premium 17% raise in april [2 words]michaelFeb 28, 2011 20:59
⇒ About Anthem Blue Cross Private Health Insurance Payments to Doctors.... [565 words]xzr56Feb 26, 2010 14:43
It's not just Blue Cross... [392 words]BobFeb 12, 2010 13:20
Premium inscrease story [149 words]Craig HolscherFeb 11, 2010 15:01
The same place JFK got the authority on steel, Teddy Roosevelt [179 words]LyleFeb 10, 2010 15:56

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