Blue Cross Blue Shield, Independent / Provider – Sponsored Plans

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Transcripts and Slides

DougBy Douglas B. Sherlock, CFA

The Affordable Care Act is intended to create strong incentives to reduce the administrative costs of health insurers. The medical loss ratio rules and the new ACA-related taxes are manifestations of this policy, and the recent announced business combinations between leading national health insurers are adaptations to these incentives.

It follows that the most recent rate of increase in health plan administrative expenses, excluding the new taxes, is dramatically lower than in recent years. Sherlock Company materials summarizing the results of our surveys are found below.

Independent / Provider – Sponsored Plans

Blue Cross Blue Shield Plans


The contents above are a very small portion of the 1,000 page Sherlock Benchmarks for each of these universes. The Sherlock Benchmarks are essential tools to manage administrative costs for your health plan.



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[Foreword Dr. Phillips MD JD MBA LLM] *** [Foreword Dr. Nash MD MBA FACP]



2 Responses

  1. Class Action Lawsuit Filed Against Blue Cross and Blue Shield of Georgia

    Former Georgia Insurance Commissioner, John Oxendine, filed a lawsuit Monday on behalf of 11 surgical centers, AllianceMed, a claims billing service, and their patients alleging that Blue Cross and Blue Shield of Georgia deliberately overcharged customers millions of dollars for coverage. The complaint consists of 14 counts that allege acts of misrepresentation, fraud, breach of contract, unfair and deceptive trade practices in the business of insurance in violation of O.C.G.A. § 33-6-4(b)(8)(A)(ii), theft by deception, unjust enrichment, conspiracy, and violation of Georgia’s RICO Statute.

    Medical billing company, AllianceMed, LLC is a plaintiff in this lawsuit. Other plaintiffs include Surgery Center of BJI, LLC; ENTI Surgery Center, LLC; ENTI Anesthesia, LLC; Urological Clinic of Valdosta Ambulatory Surgical Center, LLC; Savannah F&A ASC, LLC.; Institute for Corrective Surgery of the Foot and Ankle, Inc.; Westside Surgery Center, LLC; Surgical Centers of Georgia, P.C.; Roswell Center for the Foot and Ankle Surgery, LLC.; Ambulatory Foot and Leg Surgical Center, LLC; and East Cobb Podiatry Surgery Center, LLC.

    Source: PMNews July 28th 2015 #5,430


  2. Lawsuit Exposes Insurance Industry Secret

    “Blue Cross’s accountants and actuaries determined what expenses Blue Cross wanted to recoup through the Disputed (Hidden) Fees, and then determined how much the hospital claims charged to the customers had to be falsely marked up in order to reach that amount.”

    Darrell K. Pruitt DDS


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