Blue Cross and Blue Shield of Mississippi and the University of Mississippi Medical Center went head to head for months last year over reimbursement rates.
Turns out, it wasn’t for nothing.
An analysis by Mississippi Today and The Hilltop Institute at the University of Maryland, Baltimore County shows that in March 2022, during the throes of the dispute, Blue Cross’ negotiated rates were largely lower than other major private insurance companies — Aetna, Cigna, Humana and United — for several common procedures. This was especially true for more expensive procedures and emergency room visits.
A negotiated rate is how much an insurer has agreed to pay an in-network provider through a plan for covered services.
Hospitals perform and are reimbursed for thousands of procedures each year, but what they charge and what insurers pay has largely been kept a secret — that is, until 2021, when the federal government ordered hospitals to start publishing the data.
Mississippi Today worked with The Hilltop Institute to identify 21 common adult and pediatric procedures, then analyzed what Blue Cross reimbursed the hospital for each of those in March 2022, before the entities entered the contract dispute, and in March 2023, after the two entities renegotiated their contract.
Both Blue Cross and UMMC declined to answer any of Mississippi Today’s questions for this story.
The data show that for the selected services, Blue Cross almost never paid close to what UMMC charged, unless it was for cheaper procedures. The only exam that Blue Cross paid exactly what UMMC charged in 2022 was for a fetal non-stress test, which costs $231. (In 2023, when the cost was raised to $400, Blue Cross’ payment increased to $380.)
Hospital prices as of September 2022 show that in general, commercial negotiated rates are on average around 58% of the hospital charge for a given service, according to Morgan Henderson, principal data scientist at Hilltop.
In 2022, Blue Cross largely paid less than other private insurers for more expensive procedures, though the data shows that these insurance companies generally pay less than what UMMC charges.
According to data over the past three fiscal years from the Center for Healthcare Quality and Payment Reform, UMMC charged four times more for services provided to patients than it cost to deliver those services, which Henderson said was in line with what other hospitals charge.
Hospital charges are arbitrary — they can differ substantially from hospital to hospital. It’s rare that any payer gives hospitals the full amount they charge for any service, according to Harold Miller, CEO of the Center for Healthcare Quality and Payment Reform.
Some key findings from 2022 data show:
- Other insurers paid UMMC $250 for blood tests called total metabolic panels, $151 for comprehensive metabolic panels and $127 for therapeutic exercises. Blue Cross paid $12, $15 and $35, respectively.
- With the exception of X-rays, Blue Cross paid significantly less than other private insurers did for common radiologic procedures.
- Preventative care for kids and other services, such as chest radiologic exams and hospital observations, were more equitable compared to what other insurers paid — but they were all services that cost around or less than $150.
- Blue Cross paid more for vaginal deliveries, C-sections and fetal tests than other companies.
Henderson pointed specifically to Blue Cross’ low reimbursement rates for emergency room visits, one of the more common reasons people visit a hospital.
For the base cost of emergency room visits (not including any other services often charged during ER visits), Blue Cross reimbursed UMMC in March 2022 at far lower rates than other major insurers and what UMMC charges — by thousands.
“In light of this, the fact that BCBS Mississippi pays only $537.38 for a level 5 ED facility fee – for which the charge is almost $4,800 – is especially striking,” Henderson said.
Emergency room visits are categorized, and charged, based on severity. For a mild injury, a patient is charged a base level 1 fee, excluding any tests that might be performed during that visit. The most severe injury constitutes a level 5 emergency room visit.
And as the severity of the emergency room visit goes up, so does the charge. Depending on the level of injury, UMMC can charge anywhere from $468 to $4,796 for an emergency room visit. But for the most severe ER trip, Blue Cross reimbursed UMMC $537, while other insurance companies paid thousands more.
“This is a very good deal for BCBS Mississippi, especially when compared to the negotiated rates that other large commercial insurers pay for this same service,” he said.
As state lawmakers continue not to expand Medicaid, health care administrators across the state report that people who are uninsured and can’t afford preventative care are using the ER more often for general health care needs.
A year later, data from March 2023 shows that payments from Blue Cross for common procedures generally remain lower than other private insurance companies. In some cases, Blue Cross still pays thousands less.
The terms of UMMC’s agreement with Blue Cross, which was decided when the dispute ended in December, have not been disclosed.
Medicare rates are typically used as a gold standard to judge whether insurer payments are too high or too low. While Blue Cross rates are reasonable compared to Medicare payments, they’re still lower than other private insurers.
“I found the (Blue Cross) vs. non-(Blue Cross) price gaps for emergency and some other procedures very large, but in general what you found is expected,” said Ge Bai, a professor of health policy and management at Johns Hopkins Carey Business School, in an email to Mississippi Today.
“Large insurers can flex their muscle on the negotiating table and make threats toward hospitals, such as what (Blue Cross) did last year. Small insurers’ threats won’t be as concerning to hospitals because their beneficiaries do not account for a large portion of the hospital’s patient volume. Therefore, small insurers’ negotiated prices can be relatively higher.”
At a market share of 55%, Blue Cross insures the majority of Mississippians with private insurance, and UMMC is the state’s largest public hospital.
But according to consumer advocates, insurers with lower negotiated rates are supposed to pass those savings on to consumers in the form of low premiums, and if a for-profit company has a big surplus, larger premiums shouldn’t be necessary.
However, that doesn’t seem to be the case for Blue Cross — at least for the past three years.
Alleging they had to pay more in claims than expected, Blue Cross raised premiums in January 2020 for small business plans and individual plans. Since then, the insurance company has raised rates for individual plans at an average of 18% and small group plans at an average of 15.6%, according to data from 2023.
After UMMC asked Blue Cross for substantially increased reimbursement rates last year and Blue Cross refused, the hospital system terminated its contract with the insurance company and subsequently went out of network in April. The move forced tens of thousands of Mississippians to pay significantly more or go elsewhere for health care, including for some services that are only available at one place in Mississippi: UMMC.
UMMC houses the state’s only Level 1 trauma center, Level IV neonatal intensive care unit and children’s hospital. It is also home to the state’s only organ transplant center, where transplant candidates with Blue Cross insurance were marked as “inactive” on the wait lists when the hospital was out of network with the insurer.
During the dispute, UMMC maintained that it was asking for below-market rates for academic medical centers, while Blue Cross officials said to increase reimbursement rates, Mississippians’ premiums would have to go up.
A Mississippi Today investigation found that Blue Cross was sitting on a huge reserve of money, to the tune of $750 million.
While insurers generally try to hold at least three times as much capital as the minimum requirement — a ratio of 300% — to ensure the company can pay out claims, Blue Cross’ ratio has been around 1,600% for years, financial records revealed. It’s significantly larger than Blue Cross peers in neighboring states, and perhaps the largest such surplus by percentage in the country.
State Insurance Commissioner Mike Chaney said it was UMMC’s goal during the dispute to get closer to a 160 to 170% reimbursement rate from Blue Cross compared to Medicare.
Chaney, who advocated on behalf of consumers during the dispute between Blue Cross and UMMC, has long complained about the difficulties in regulating insurance reimbursement rates. He has previously said that Blue Cross won’t make that data available to his office.
New health care price transparency rules, which went into effect in 2021, requires hospitals and insurers to publish their rates, but that doesn’t mean those numbers are easy to access. They’re published on an individual basis, hospital by hospital, and the files, which don’t always look the same, are huge and sometimes hard to decipher.
Gov. Tate Reeves axed a bill earlier this year that would have allowed Chaney’s office the authority to study and address inequalities in reimbursement rates among insurance companies. The bill, which Reeves called a “bad idea,” would have allowed the commissioner to fine companies thousands per violation if they can’t justify unequal reimbursement rates for different hospitals for the same procedures.
“Transparency should provide policy-makers an understanding of what is contributing to the critical financial issues hospitals, clinics, and health providers are facing,” said Mitchell Adcock, executive director of the Center for Mississippi Health Policy. “If payments are not equitable, there are no other financial sources that provide enough revenue to cover health providers' costs.”
And as state leaders continue to oppose expanding Medicaid to the working poor, providers rely on private insurance company payments to offset uncompensated care for people who are uninsured.
Uncompensated care and higher health care costs have worsened the state’s hospital crisis. A third of rural hospitals in Mississippi are at risk of closure.
“The current hospital revenue model, good or bad, is private insurance payments to help cover the limited payments from Medicare and Medicaid and help offset some of the uncompensated care cost,” Adcock said. “Therefore, private insurance payment rates have a significant impact on hospitals’ ability to operate.”
Correction 6/13/2023: The 2022 chart has been updated to correctly reflect what UMMC charged for CT scan and MRIs.