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[Music]
DAN: One of the things that's driving up the
cost of care is a new term
It's called pass-through billing
and today we're here with Shara McClure,
who is a Divisional Senior Vice-President
of Health Care Delivery.
So, Shara what is pass-through billing?
SHARA: So stick with me it's kind of complicated.
DAN: Okay.
SHARA: But as you know we negotiate for the
prices that we pay to our providers.
Some providers negotiate higher prices and
other providers negotiate lower prices.
Well sometimes if a provider with a
lower price somehow convinces the provider
with a higher price to bill
on their behalf even though that
higher price providers not providing the service,
that's what pass-through billing is.
DAN: Okay so let me get this right.
SHARA: Alright.
DAN: So I could decide to make a decision
to go to a higher value, let's just say hospital,
okay because I'm having a procedure done,
and at the hospital I get a service done
and I'm gonna say laboratory right and
I get my lab done an the bill comes from
the hospital where I had the service done
but are you telling me that the rate I’m paying
might be from someone else who's just using that
hospital to bill it?
SHARA: It could. It could be from another hospital
it could be from a hospital in another state
it could be from a hospital that had absolutely nothing
to do with the service that you were provided,
you can even go to a Doctor’s office.
DAN: Okay so this sounds kind of shady to me.
It sounds like that people are using contracts
to just take as much money from
a patient as they can. Is that what's happening?
SHARA: I think that's accurate. That's what
we're seeing and when we find it
we address the contract, we address the provider,
there have even been some legal implications
around licensure because maybe the
higher price provider doesn't even have
no licensure to provide the service.
DAN: I think I saw an example is that where,
where somebody had a surgery done and
they got a pathology bill but there's really no
pathologist even working for the hospital.
Is that fair? Something like that.
SHARA That can be fair, yes.
DAN: So the other thing that's a little
shady about this is that patients
may never know.
SHARA: Patients might not know
until they get their bill or their explanation
of benefits after the fact.
DAN: And then what do you do about it?
SHARA: So if so let's say you get an
explanation of benefits or a bill and
it's from a provider or describes…
it might describe the service that you
received but if it's by a provider that
you had no knowledge of accessing then
that could be a pass-through bill
situation.
DAN: So in other words it's almost a type of fraud?
SHARA I think that in certain circumstances
it is identified as fraud.
DAN: So if the patient finds an example about
that then they should call the number on
the back of their insurance card and ask
questions and figure out what's going on.
SHARA: Absolutely and it could have
you know it could have out-of-pocket implications
for that patient as well.
DAN: Well, Shara we're always looking for things that
we can shut down that you know arbitrarily
raise the cost of health insurance
and healthcare and it sounds like this
pass-through billing is something that needs
to be shut down.
SHARA: Absolutely.
DAN: Thanks for being here today. Thanks for
joining us for this episode of blue Promise.
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