This will have some long-term consequences for the industry but makes a good case for Self Funding with an Independent TPA & Independent Network Solution. Blue Cross was essentially doing what is common practice in the PBM industry – paying the service provider one amount while billing the Plan Sponsor a much higher amount and pocketing the Spread -which in this case appears to have been 22%. It’s common knowledge in the industry how BC will have separate reimbursement schedules depending on whether the client is fully insured with them or self-funded. As the article points out, the Self-Funded clients never realized the great discounts they were expecting.
Summary: If a company with low claim experience stays with a BC fully insured plan – BC wins. If that client goes Self Funded with BC, BC monkey’s around with the reimbursements and wins again. Yet another example of why Transparency and a Referenced Based Reimbursement model is the way to go.
Blue Cross Hidden Fees & Self Dealing (Huffington Post Article – 05/11/2015)