Charge-master manipulation to breach caps

In Episode 472, Stacey Richter speaks with Dr. Eric Bricker about the impactful strategies hospital systems use to maximize revenue from high-cost patients. They explore the financial complexities and contracting tactics that enable hospitals to profit significantly from a small percentage of high-cost claimants.

Key points include the negotiation of provider stop-loss contract provisions, strategic adjustment of charge masters, and the intentional steerage of patients to high-revenue service lines. This episode highlights the intricacies of hospital finance and the hidden mechanisms that drive healthcare costs for self-insured employers and other plan sponsors.

We could have 0.5% to 1% of total plan members costing upwards of 40% of total plan dollars. And I bring this up just to highlight the magnitude of the money here. In that show from last week, we take the issue of high-cost claimants from the standpoint of the plan sponsor.

Today, however, we're gonna be looking at this from the standpoint of the hospital system. If we were to come up with a motto for the show today with Dr. Eric Bricker, it's that all costs are somebody else's revenue. And when it's revenue and profit of the magnitude that we're talking about with many high-cost claimants, it starts to be less of an accidental "Oh, wow! How did that CABG patient wind up in our clinic? What are the odds?" and more of a "Whoever is not steering patients is letting someone else with a big profit incentive lock down that steerage in deeply embedded ways."

=== LINKS === 🔗 Show Notes with all mentioned links: https://cc-lnk.com/EP472

📺 Dr. Bricker's AhealthcareZ Channel www.youtube.com/@ahealthcarez

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05:06 From a hospital revenue perspective, where do high-cost claimants fall?

08:45 How do hospitals structure their stop-loss provisions so that they ensure they're always maximizing their revenue?

12:15 How hospitals acquire providers to steer as many patients as possible through specific service lines.

20:21 Why do carriers let hospitals get away with these rates and stop-loss negotiations?

21:06 How do Medicare Advantage and Medicare rates play into all of this?

22:00 What should a benefit consultant be doing here?

23:37 What are the keys to direct contracting?

27:21 Why is it important to get trusted relationships set up ahead of time?

28:04 The Company That Solved Health Care by John Torinus Jr.

29:23 What needs to be the clinical consideration for specialists?

30:46 What is the advantage that employers have in all of this?

33:06 Dr. Bricker's video on 32 examples of healthcare deception.