Next 30 days crucial for State Treasurer — ‘Clear Pricing’ aims to slow health care costs

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RALEIGH – State Treasurer Dale Folwell in conjunction with the State Health Plan announced this week the launch of a new Participation Agreement – a contract used by Blue Cross of North Carolina to create a custom ‘provider network’ for 720,000 people covered by the Plan.

Blue Cross is the Plan’s third-party administrator and, as such, contracts directly and indirectly with health care providers, intermediaries and provider organizations to provide, arrange for, or administer the delivery of covered medical services to Plan members.


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The new network is being developed as part of Folwell’s ambitious Clear Pricing Project — intended to adopt reference-based, transparent government-pricing model tied to Medicare rates. The goal, of course, is to slow run-away health care costs – which many experts attribute to local hospital monopolies that have practically eliminated any public understanding of fees charged across the entire spectrum of medical services

Under the new contract and network, the Plan is expected to offer increased reimbursement payments to most independent primary care physicians, behavioral health specialists and many rural hospitals.

Medicare mandates and clearly publicizes the fees that it pays for almost any procedure. Folwell’s plan takes those existing fees, and adds a profit – 60-plus percent for some of the “top utilized codes.’ The latter term is lingo for commonly offered treatments – with every procedure assigned a numbered code.

But, the fly in the ointment, is that Folwell’s proposed payments are less than what the Plan has been paying for decades. In other words, the state’s mega hospitals fear that the Clear Pricing Project will affect their bottom lines.

Contracts (what the Plan will pay for medical services) are scheduled to be sent out by the end of the week. Medical providers will have until June 30 to return the necessary documentation to be part of the State Health Plan Network. The new network will become operational on January 1, 2020.

At the request of this newspaper, Folwell’s staff submitted this recap of prices the Plan expects to pay for some of the most common health care procedures: