What's a Per Diem?

Blue Cross and Blue Shield of Alabama contracts with hospitals in state to pay a fixed amount per day for an inpatient stay.  It generally doesn't matter why you go to the hospital.  If you go for a sinus infection, liver transplant, or bunion removal, Blue Cross will reimburse the same fixed amount for every day you stay in the hospital.  Each hospital has their own per diem and Blue Cross doesn't publish them, so we don't know what they are.  Looking at the hospital bill, or EOB doesn't tell us anything.  Your EOB will have total charges and covered amount.  Neither of these is the per diem and have nothing to do with how the per diem is calculated.  If you have coinsurance as part of your out of pocket payment you may be able to back into the per diem.  Blue Cross Alabama is one of a few plans that reimburses by per diem.  Most other Blue Cross plans pay by DRG, or Diagnosis Related Group, which pays an amount for the entire stay based on condition and not number of days.  If you have Blue Cross Alabama insurance and have a hospital stay in Florida you'll get the discounts from Blue Cross Florida, not Alabama. 

Here's an example of how an inpatient claim may process using $2,000 as the per diem. 

You stay in the hospital four days and have a $200 inpatient deductible. 
Total allowed amount, or due the hospital would be $8,000 ($2,000 X 4 days).  You pay the $200 deductible leaving your group health plan to pay $7,800. 

ZBL - Part 1

ZBL means Zero Balance Logic.  It's a pharmacy contracting term meaning members on a health plan will pay the lower of copay or U&C.  So what exactly does this mean?  Most people with pharmacy coverage will pay a fixed copay for prescription drugs.  A typical benefit design would be $10 for generic drugs, $30 for preferred brands, and $60 for non-preferred brands.  With ZBL off if you buy a drug that costs less than $10 you would pay the lower amount, not the full $10.  A good example is Hydrochlorothiazide, or HCT, a common blood pressure medication.  Under most plans this drug would cost around $3.  With ZBL turned on you would pay the full $10, not the $3.  The exception would be if the U&C (usual & customary) price was lower.  The U&C price is what a customer without insurance would pay.  Wal-mart $4 drugs are an example of U&C.  You would pay $4 regardless if you had insurance.  Why would any health plan use ZBL and force their employees to pay more for a drug than necessary?  That's a good question.