No announcement yet.

Out of Network Billing

  • Filter
  • Time
  • Show
Clear All
new posts

  • #16
    Ok, I have been sufficiently disturbed by this thread all day (as my entire business model rests on voluntary office-based outpatient out-of-network billing mutually agreed upon between me and the patient) to look into it. The proposals I have been able to find all relate to limiting out-of-network charges for hospital-based services and particularly for "surprise" and involuntary charges. I haven't seen any legislative proposal in the US -- state or federal -- to limit out-of-network billing across the board or for outpatient services or for voluntary medical services. Certainly there is a "slippery slope" issue here, but I would think that voluntary outpatient services would be the last area to which limits would be applied. What am I missing?
    My Youtube channel:


    • #17
      In NY state we have the surprise bill law. It limits out of network fees to 120% of UCR (the reasonable charge). For the ED docs, this works well.


      The NY law prevents providers from gouging the patient for unscheduled and emergency care, and it prevents insurers from forcing us to be in-network at a terrible rate that they unilaterally set.  For scheduled care, the provider has to notify the patient of the out of network charges up front or the patient won't be responsible when they receive a "surprise bill" for the out of network charges.


      What scares me is that other states have passed laws forcing ED and other facility based docs (rads, anesthesia, hospitalists, pathology, etc.) to be in network, but it appears that these laws force the docs to be in network without guaranteeing a reasonable fee.


      If you have a chance in other states, send your legislators a copy of the NY surprise bill. I feel it is balanced and fair to all parties.  It protects patients, doctors, and insurance companies in a balanced fashion.


      • #18
        I like the NY model.  But the insurers weren't interested.

        Same with the TX model.

        Same with the NCOIL model.

        Same with variations/combinations of each of these.

        Next effort: Fairhealth.

        Rex, on a doctor financial forum I'm being a bit hyperbolical.  Ultimately it is the patients who are caught in the middle, whether it is the rare unscrupulous doctor or the larger network adequacy situation where they lose access to care.  Although I work in a big hospital, we still have a very thin safety net among specialists.  (As an example, for the longest time, we had no orthopaedists that accepted Medicaid in clinic.  Luckily, that payor is only 1 out of every 5 of my patients.)  One recent legislative effort to cap charges would have cut my salary in half.  Yes, I am paid well, but I am not going to take a 50% pay cut (I guess at least my taxes would have been less...).  I will practice elsewhere by way of locums or just retire.  Either way, my community loses an experienced doctor.  Perhaps I would be the only one to quit, but that is a heck of a gamble on the part of the legislature.


        • #19
          Which states are potentially affected by these bills to reduce/eliminate out of network billing?


          • #20

            I think few would quit so I’m not sure it’s that much of a gamble. As you know it’s then more like a 25% cut in pay after taxes. Not pleasant but still putting docs in the top 10% on income so I doubt we get much sympathy.

            Medicaid is a very low payer but one still can survive seeing some Medicaid. Thing is none of those orthos were willing.

            Now I actually hope that we all make great money while delivering great care. I just can’t agree with these crazy high charges. Somebody else’s wrong doesn’t allow us to do so.
            Click to expand...

            Depends on ones specialty. For me, this would affect 95% of my billed time. Medicare fees for psychiatric services are woefully inadequate, particularly in the HCOL environment of NYC and environs. I think a large number of practitioners would be severely affected. At age 58, I'd opt for stopping and relocating (as ultimately planned anyway) to a LCOL area near family and tightening the belt a little.
            My Youtube channel:


            • #21
              Rex, I just can't resist to share this story!  I scheduled Rotorooter this morning (first appt of the day at the crack of 9am) for a clogged drain.  10 minutes late.  35 minutes on-site.  $215.  And this isn't even the fancy hydronics guy!

              Pistolpete, the list of states considering legislation changes each year; as mentioned above, some states have figured it out.  In the EM world, the state chapter of ACEP would likely be of service.  Your profile lists you as a resident.  What do you think, would income comparisons have any bearing on where you choose to practice after residency?


              • #22

                He isn’t making 430 an hour. Average salary is 22 an hour.
                Click to expand...

                Yes because there is overhead and costs.  Similar to doctors providing care.  Much of the public thinks the doctor keeps every dollar paid by the patient and/or insurance.