Out-of-network reimbursement drives in network reimbursement.
Why would any insurance company contract for rates greater than Medicare if out-of-network rates will be capped at 100% of Medicare?
All doctors, not just those of us that treat out-of-network patients need to aggressively fight this.
Consumer point of view:
Medicare, insurance, copay, cash? Whatever it is should be reasonable and an arms length transaction.
The current balanced billing is a fiasco. Bad behavior on insurance companies and providers. Simply stated:
1) A large hospital system gets better reimbursement rates than the smaller groups or pp. Sometimes, competing hospital systems are played against each other.
2) A hospital is “in network” but outsources almost all of the services and providers and separate billings CLEARLY reflect out of network rates.
3) Chargemasters are useless. A patient has no idea which codes you are planning to throw in there.
4) SOME display signs that they accept insurance plans and credit cards. Yes, they submit, are out of network, insurance denied due to out of network. The charge additionally is way over ANY in network price. On top of that, their is a 15% markup for using a credit card. The reason is the ability of a patient to protest . No insurance, prices from heaven and stick it to the patient that has zero expertise in protesting. Mean while the provider has staff trained to handle “billing disputes”.
“123 main st any town USA” will NOT accept a New York solution. Period!
Too many games. I hear your complaint about Medicare prices. It is the “best of the worst options”
I hear your complaint about insurance reimbursement, it is the “second best of the worst options”. SOME physicians have ruined public trust in a physician setting fair prices.
Flu vaccine
Facility fee
Provider fee
Observation room
Payment method
Total cost
The games played lead to a patient being screwed without ever see a physician.
Up front, tell the patient or assume responsibility for the writeoff. My apologies to the great New Yorkers, it happened before and I hope you get some relief from some of the poor outcomes. Not interested in “artbitration panels or lawsuits like New York or permitting balance billing.
So, as a consumer, no difference to you.
Medicare rates are unsustainable for most specialties
Why would you base your reimbursement on Medicare rates when they are set based arbitrarily without reason and pay below normal market share?
because you don’t want to negotiate every last little procedure and visit code?
in some ways everything is arbitrary. we’ve always pegged it to medicare rates. we’ve always been successful at maintaining rates above medicare levels, but there is always stress during the negotiation period. how do you guys do it? i’m open to learning better ways.
Why would you base your reimbursement on Medicare rates when they are set based arbitrarily without reason and pay below normal market share?
because you don’t want to negotiate every last little procedure and visit code?
in some ways everything is arbitrary. we’ve always pegged it to medicare rates. we’ve always been successful at maintaining rates above medicare levels, but there is always stress during the negotiation period. how do you guys do it? i’m open to learning better ways.
You’re going about it the wrong way. You negotiate your RVU’s and base your procedures and E&M visits based on RVU’s. You negotiate individual procedures that are most common. In the ER, one would negotiate RVU reimbursement and then negotiate how many RVU’s you get for a CVL, intubation, I&D, etc. The rest you base on the provided CMS work RVU model (or total RVU’s if you need to count overhead and malpractice in your negotiations).
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