Insurances Taking Advantage of Practitioners

[Dahlers and Sense]

Hello,

I was wondering if anyone has had any success navigating similar obstacles that I am having. I am an independent hospitalist contracted at several hospitals. I have been having issues with getting on insurance panels. Some of the panels such as United Healthcare are not taking any new providers and others like BCBS & Aetna etc are reimbursing at approximately 60% of medicare rates. When I submit a bill to United even out of network, they do not pay a cent. Thankfully, the bulk of my patients are medicare. I have spoken to several colleagues and there have been no new colleagues that I am aware of who have been allowed on some of the panels in the past several years as independent practitioners. My hospitals will continue to accept these patients as the hospitals are contracted and receive payments. Any recommendations?

[jacoavlu]

I don't mean to be combative, but how are the insurers "taking advantage" of you? We like to think it's a free market, operating with principles of supply and demand. It's not that simple of course, but the principles are still there.

Sometimes physicians have power in such negotiations, sometimes they don't.

[nephron]

That's pretty annoying, can patients with those private insurers go to another hospitalist? Maybe tell the hospital administrators that you will not admit patients with those insurers unless they get the insurers to make you an in-network provider. I don't know how hospitals get all of their employed hospitalists as in network providers or if they just absorb the loss when insurers refuse.

[Dahlers and Sense]

One of the major hospitals I work at is actually an inpatient rehab hospital. There are 4 other providers there (all independent) and all of us have applied for United Healthcare and been denied. Some were denied from BCBS, but I was "lucky enough" to get on at a rate of 60% of medicare. If we went to administration and complained that we didn't want to see a certain patient / insurance they would simply find someone else to do it as the hospital there are other practitioners that would love to have a job at the hospital and would be happy to eat the cost of not getting paid by certain insurances. Unfortunately, the patients get hit with bills from us (at medicare rates) and there is no incentive for the insurance companies to let us on the panels.

[southerndoc]

Even further reason to stay in the fight for balance billing legislation that is fair. It will be introduced again in 2020.

[Tim]

Dahlers and Sense
“ If we went to administration and complained that we didn't want to see a certain patient / insurance”
What would administration say if all four asked for assistance getting paid for patients that have United Healthcare ? Admin is great on admin, patients are your problem. Give them the chance to shine! Frame the question differently. They can say no. So what, it’s worth a shot.

[HandFellow]

there is strength in numbers. if you and your colleagues can work together in some way, perhaps you can negotiate from a position of strength. It will be difficult as a solo practitioner.

[Cubicle]

I wish I had advice... I was even going to post about my brewing "war" with an insurance company. Their pay has been terrible, less than 50% of Medicare, but understandably it is state HMO Medicaid. Not a single increase in reimbursement in over 4 years. Every time I request an increase their response is "we don't have it in the budget".

Last week they sent me a letter & I probably can't get into specifics, they used some words that I find personally offensive to my character, & as a doctor. I have plans to contact the provider representative about it. If we can't agree to resolve the issues in the letter or provide me with a rate increase, I will be pulling myself from their network. This company represents ~20% of my yearly income. But the work amount & stress level are more than my typical Medicare patient, so I don't think I will cry about it.

All that is to say, going in I knew one day they would be on my chopping block. I have always looked at it as certain income. No deductible, no copay, no coinsurance. And one day when I didn't need their stability, I would be cutting them. You, Dahlers and Sense, might want to see your situation this way. Maybe bite the bullet for now & re-assess in the future. It is off putting to say the least, but sometimes it works out in other ways.

Another specialist near me cut the same insurance I'm fuming with last year so I got a influx of patients looking for an in network doctor then. I completely knew why he did what he did, he wasn't wrong. Now I'm in his shoes.

[Zaphod]

I don't mean to be combative, but how are the insurers "taking advantage" of you? We like to think it's a free market, operating with principles of supply and demand. It's not that simple of course, but the principles are still there.

Sometimes physicians have power in such negotiations, sometimes they don't.

There is no side of the healthcare market that even approximates loosely a free market. Its take it or leave it for patients and practitioners.

[jacoavlu]

There is no side of the healthcare market that even approximates loosely a free market. Its take it or leave it for patients and practitioners.

that hasn’t been my experience, in private practice, hospital based specialty, small group

as a solo provider it sure could be take it or leave it as far as insurance contracts go, but that doesn’t mean it isn’t a free market. OP just doesn’t have a position of strength in negotiations

[Zaphod]

that hasn’t been my experience, in private practice, hospital based specialty, small group

as a solo provider it sure could be take it or leave it as far as insurance contracts go, but that doesn’t mean it isn’t a free market. OP just doesn’t have a position of strength in negotiations

That is in no way definition of free market. Insurance sets prices and you can negotiate around them, they are not based on a competitive model. Insurance and hospital delivery is monopoly/oligopoly at best and they have the final say in the end. They can deal with you, as long as you arent a concern for them, but they dont have to.

[youngDoc]

Medicare dictates payment and commerical insurances use Medicare schedule to dictate payment. Scope of practice anis restricted regulated for doctors and mid-levels. Doctors frequently lobby government agency to enforce these regulations. I wouldn't say that it is a bad thing, but it's not a free market.

[EM-CCM MD]

I have no person experience, but it seems like you should either try to have a sit down with whomever the highest ranking local person is. If they won’t do that, I’d try to win the battle in the court of public opinion.

You’re doing the right thing. You’re a freaking hospitalist trying to get in-network billing for the patients that come to you. I’d go to the local news, newspaper etc. Probably won’t do anything, but screw those guys.

[jacoavlu]

That is in no way definition of free market. Insurance sets prices and you can negotiate around them, they are not based on a competitive model. Insurance and hospital delivery is monopoly/oligopoly at best and they have the final say in the end. They can deal with you, as long as you arent a concern for them, but they dont have to.

So you think supply and demand has nothing to do with the OPs situation?

[Tim]

They can deal with you, as long as you arent a concern for them, but they dont have to.

And you can deal with them, as long as they aren’t a concern for you, but you don’t have to.
That is exactly the definition of a free market. Everything else is negotiable.
By no means is free market fair.