Out of Network Billing

[CB]

Checking in to see if any docs in the White Coat Forum are planning on a decrease in income when the feds/state disallow out of network billing for all specialties. White Coat's advice on keeping expenses low is CRITICAL to your bottom line as this issue gets sorted out in the state capitals and at the federal level.  Private groups across hospital and non hospital based specialties are selling out to CMGs rapidly. EM(my field), Anesthesia, Path, Rads, Cards, Surgery, IM, Hospitalists all in the cross hairs now. Interested to hear how docs across specialties dealing with issue in their practice. How do you plan to make up the lost income? State imposed caps looking ugly with rates slapped down to low multiples of medicare.

White Coat--this may be a good poll topic as I see Utah is in the cross hairs now. Insurance companies have successfully changed their 'surprise coverage' into 'surprise  bills."  Most legislators think fair payment is medicare rates and anything more like Fair Health is too complicated. Most docs(private, employed, academic...) do not even realize this freight train is coming at them if they are not running the business end of the practice.

CB

 

 

 

[CM]

CB wrote:

Checking in to see if any docs in the White Coat Forum are planning on a decrease in income when the feds/state disallow out of network billing for all specialties. White Coat’s advice on keeping expenses low is CRITICAL to your bottom line as this issue gets sorted out in the state capitals and at the federal level.  Private groups across hospital and non hospital based specialties are selling out to CMGs rapidly. EM(my field), Anesthesia, Path, Rads, Cards, Surgery, IM, Hospitalists all in the cross hairs now. Interested to hear how docs across specialties dealing with issue in their practice. How do you plan to make up the lost income? State imposed caps looking ugly with rates slapped down to low multiples of medicare.

White Coat–this may be a good poll topic as I see Utah is in the cross hairs now. Insurance companies have successfully changed their ‘surprise coverage’ into ‘surprise  bills.”  Most legislators think fair payment is medicare rates and anything more like Fair Health is too complicated. Most docs(private, employed, academic…) do not even realize this freight train is coming at them if they are not running the business end of the practice.

CB

 

 

 

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I'm one of the employed physicians unaware of the freight train. Can you provide more explanation/context?

[VagabondMD]

I think that for our radiology group, this is a non-issue. We are contracted with all of the major payers in our area and rarely get compensated on billed charges.

 

[Antares]

All my billing is out of network, so no change for me.

[pulmdoc]

Physicians are not obligated to accept insurance plans for reimbursement, however they are out of network so patients are disincentivized to see them. There has been a flurry of news articles about huge surprise bills from "behind the scenes" doctors (anesthesia, path, etc) where the patient thought they did everything right to be in network but a doctor they had no control over choosing generated a huge out of network bill. One egregious example that sticks in my mind was an article about a patient who had back surgery, something straightforward like a 2 level neck fusion. The primary surgeon bill was something like 1k. The surgeon's partner scrubbed in as first assist and billed 100k out of network which the patient was on the hook for. Investigation showed that the first assist surgeon refused all insurance and did first assist on all non-governmental patients (Medicare caps first assist to I think 15% of primary surgeon bill) to generate these humongous bills. Another example shared by one of my own patients was that his back surgery cost 3k, but the intraoperative neuro monitoring doc (who has a tech in the room and just reviews the tracings later) charged 25k because out of network. I think it's hard to generate sympathy from the public based on these cases.

[CM]

pulmdoc wrote:

Physicians are not obligated to accept insurance plans for reimbursement, however they are out of network so patients are disincentivized to see them. There has been a flurry of news articles about huge surprise bills from “behind the scenes” doctors (anesthesia, path, etc) where the patient thought they did everything right to be in network but a doctor they had no control over choosing generated a huge out of network bill. One egregious example that sticks in my mind was an article about a patient who had back surgery, something straightforward like a 2 level neck fusion. The primary surgeon bill was something like 1k. The surgeon’s partner scrubbed in as first assist and billed 100k out of network which the patient was on the hook for. Investigation showed that the first assist surgeon refused all insurance and did first assist on all non-governmental patients (Medicare caps first assist to I think 15% of primary surgeon bill) to generate these humongous bills. Another example shared by one of my own patients was that his back surgery cost 3k, but the intraoperative neuro monitoring doc (who has a tech in the room and just reviews the tracings later) charged 25k because out of network. I think it’s hard to generate sympathy from the public based on these cases.

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These are muggings.

[pulmdoc]

Yep, hence the proposed legislation to stop them.

[VagabondMD]

pulmdoc wrote:

Physicians are not obligated to accept insurance plans for reimbursement, however they are out of network so patients are disincentivized to see them. There has been a flurry of news articles about huge surprise bills from “behind the scenes” doctors (anesthesia, path, etc) where the patient thought they did everything right to be in network but a doctor they had no control over choosing generated a huge out of network bill. One egregious example that sticks in my mind was an article about a patient who had back surgery, something straightforward like a 2 level neck fusion. The primary surgeon bill was something like 1k. The surgeon’s partner scrubbed in as first assist and billed 100k out of network which the patient was on the hook for. Investigation showed that the first assist surgeon refused all insurance and did first assist on all non-governmental patients (Medicare caps first assist to I think 15% of primary surgeon bill) to generate these humongous bills. Another example shared by one of my own patients was that his back surgery cost 3k, but the intraoperative neuro monitoring doc (who has a tech in the room and just reviews the tracings later) charged 25k because out of network. I think it’s hard to generate sympathy from the public based on these cases.

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I agree. Some colleagues, who are medical scammers, have made it difficult for those of us who try to play by the rules and bill fairly.

[The White Coat Investor]

CB wrote:

Checking in to see if any docs in the White Coat Forum are planning on a decrease in income when the feds/state disallow out of network billing for all specialties. White Coat’s advice on keeping expenses low is CRITICAL to your bottom line as this issue gets sorted out in the state capitals and at the federal level.  Private groups across hospital and non hospital based specialties are selling out to CMGs rapidly. EM(my field), Anesthesia, Path, Rads, Cards, Surgery, IM, Hospitalists all in the cross hairs now. Interested to hear how docs across specialties dealing with issue in their practice. How do you plan to make up the lost income? State imposed caps looking ugly with rates slapped down to low multiples of medicare.

White Coat–this may be a good poll topic as I see Utah is in the cross hairs now. Insurance companies have successfully changed their ‘surprise coverage’ into ‘surprise  bills.”  Most legislators think fair payment is medicare rates and anything more like Fair Health is too complicated. Most docs(private, employed, academic…) do not even realize this freight train is coming at them if they are not running the business end of the practice.

CB

 

 

 

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We are in the cross-hairs now. In the last 48 hours I've emailed my Rep, my Senator, and the author of the bill (two of whom were also part of the gang who tried to make a physician license cost $5K a couple years ago).

[The White Coat Investor]

Antares wrote:

All my billing is out of network, so no change for me.

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That's exactly the issue. All my billing is in network, but the bill as proposed basically sets prices for out of network care without any input from the doc.

[G]

We've been fighting this in my state for years and years.  Obviously the insurance companies don't want to be fair, particularly for ER care which is mandated by law to care for the patients.  Multiples of medicare sound like a great deal to lay public/legislators.  Why would a greedy doctor not be happy with 200% of medicare?!

Putting things in perspective helps:  Perhaps we should cap the plumber's wage at 200% of minimum wage.  Good luck finding somebody to fix your broken pipe.  (Perhaps we should also have a law that says the plumber must fix your pipe at any time of day or night whether you intend to pay him or not.)

If it passes in my state, I'll see how payment shakes out.  If it is a huge pay cut, I'll quit.  The legislators and insurers can figure out how to take care of sick people at 3am.

[CB]

White Coat has it right on this topic. Stay informed. Live below your means. Without cost shifting MD practices lower group salaries to cover the folks with low/no payments. The out of network issue is like a Jenga block supporting hospital/MD payment to cover the under/uninsured. Basic Health Care Finance.

G--your comments are right on. I expect to see many docs retire early/leave medicine when this train runs it's course.

Pulmdoc-totally agree hard to generate sympathy when facility side charges get mixed up with the docs as is the case when you see numbers like 100k. Skilled PR by the insurance cos working every angle.

My post to the forum stems from 30 years of private practice managing a large MD group and 15+ years on the Finance Committee of my hospital. Over and over I find colleagues who are not aware of how a paycheck is created. No matter how you slice it cost shifting from insured patients covers a big part of MD salary to make up for the under/uninsured patients. Transparency of all pricing is key to understand how cost shifting is embedded in every MD salary-unless you are cash only.

CM-Many docs are out of network due to low payments from insurance companies hence docs stay out of network for fair payment. Instead of negotiating in good faith insurance companies will not pay fairly and have portrayed docs as the bad guys. Simply not true. By legislators setting low out of network rates even the in network docs will get nailed  with a race to the bottom in this budget neutral environment. No leverage in a rate setting environment. Insurance Cos looking for any and every way to reduce payments to docs--everyone. Fair Payment is key definitely not tied to low Medicare/Medicaid rate multiples. Worth everyones time to see how you may unwittingly fit into the payment puzzle given rate setting at the state/federal level with impact every non cash only doc. There is legislation pending in dozens of states across the US. Don't fall for the click bait of a $19,000 hangnail---fake news.

Rex--I agree egregious charges are terrible. When you look at huge data bases like Fair Health a not for profit independent data base of healthcare pricing you can get a much better idea about pricing in the healthcare market place. Transparency is key.  https://fairhealthconsumer.org/whoweare.php

 

 

 

 

 

[G]

How is this not a realistic comparison?  There is no negotiated rate for federal insurance--you take what you get.  Medicare and medicaid is better than nothing, but for ER care, it does not pay the bills.  Nor does 2x medicare.  To be a little cheeky, if you have a job that you are forced to do something and forced to accept whatever someone chooses to pay you, sounds a bit like indentured servitude, no?  As for being treated like a plumber, my plumber's hourly charge is more than a hospitalist makes and he doesn't answer his phone in the middle of the night.  Nor does he work on holidays or Sundays.

I DO think that we should have legislation; in fact, year after year we propose ways to set equitable payments (for insurer and provider) and mechanisms to protect patients and punish bad doctors.  It has always failed because the insurers have zero motivation to do move forward with this legislation.  They collect their premiums, pay their executives and send out dividends to the shareholders.  So they make money by deliberately underpaying and when that dishonest doc comes along it gives them good press.

And the people that suffer most are the patients.

[Zaphod]

There has been lots of press in California on this in the past couple years since a group of surgery centers sprung up based on this principle, charging insurers like 90k for a knee scope, etc...The insurers used to just pay since it was the agreement, but a pt is the one who was so fired up about it that it started getting some light.

Obviously its basically criminal and puts the whole system on worse footing, but no one cares individually that they are ruining every other charge for all doctors even themselves in the long run, as long as they profit now. Its really too bad.

[Antares]

I haven't heard anything about this here in NY, but I can't see how I could remain in practice with significant limits on out of network billing rates. Nor could the many other psychiatrists in the NYC metro area. Honestly, I can't see such a thing being enacted here.