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Balance billing call for action

Home General/Welcome Balance billing call for action

  • Dreamgiver Dreamgiver
    Participant
    Status: Physician
    Posts: 898
    Joined: 03/09/2017

    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.

    Click to expand…

    Bingo!!!! That is exactly why.

    #225536 Reply
    Liked by Zaphod
    Dreamgiver Dreamgiver
    Participant
    Status: Physician
    Posts: 898
    Joined: 03/09/2017

    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.

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    I understand your take and agree with it. However, Medicare rates are unsustainable for most specialties. I don’t think the NY solution is the best but it is better than letting insurance companies start reimbursing at medicare rates. The arbitration is between the providers and the insurance companies, the patient is left out of it as balance billing is just done away with. So, as a consumer, no difference to you.

    #225539 Reply
    Avatar Tim
    Participant
    Status: Accountant
    Posts: 3381
    Joined: 09/18/2018
    So, as a consumer, no difference to you.

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    I have zero problem with that.

    Medicare rates are unsustainable for most specialties

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    I have zero problem with that.

    Would a % above in network rates work?

    Medicare, in network, out of network? The insurance companies would have an incentive to get providers to sign up. I completely understand the contention between medicare and insurance companies and providers. The balance billing is to the consumer and many times from a hospital as well. The consumer is at a huge disadvantage. That was my point. I have no problem with a provider saying “no thanks” because of pricing. You need to earn a living. Better solution than blowing up individuals particularly when they have paid through the nose and have been honest. The same rates need to apply with or without insurance. What I object to is “huge amounts billed and significantly lower amounts actually paid”. It’s a price negotiation on everything. Seems to be a better way.

    #225553 Reply
    Avatar Mednole
    Participant
    Status: Physician
    Posts: 12
    Joined: 05/15/2016

    Florida passed a balance billing law in 2015 that essentially holds the patient harmless. It’s up to the provider and insurance company to agree on terms or a state sponsor arbitrator gets involved. Most importantly, usual, customary, reasonable charges is not defined in the legislation and is up to the arbitrator/courts to determine what UCR really is.

    #225555 Reply
    Avatar Mednole
    Participant
    Status: Physician
    Posts: 12
    Joined: 05/15/2016

    If I’m on call and see a patient with an out-of-network insurance in the ER with a condition that requires emergency surgery (regular occurrence), what is a fair price?

    it was mentioned that a percentage above in network rates would be fair. However, who determines “in network rates” when every provider negotiates their own rate to join network?

    Aetna refuse to offer me a contract above 75% of Medicare when I started my own practice. It took about a half a dozen out-of-network emergency cases until I had the end of rep calling me three or four times over two days begging me to accept 120% of Medicare.

    Without the leverage of being able to bill insures out-of-network rates, solo/small groups lose all leverage.

    #225610 Reply
    Avatar Tim
    Participant
    Status: Accountant
    Posts: 3381
    Joined: 09/18/2018

    “Without the leverage of being able to bill insures out-of-network rates, solo/small groups lose all leverage.”

    Does the ER accept any insurance?
    Does Aetna cover any ER?
    Pick the highest and tack on a premium.
    I really hope it’s not a made up number that’s 4 times greater that you decide to punish the patient rather than the lowball offer. The point was allow you leverage with the insurer. Balance billing screws the guy in the hospital, did Aetna pay or what happened to the patient?

    #225620 Reply
    Avatar Mednole
    Participant
    Status: Physician
    Posts: 12
    Joined: 05/15/2016

    “Balance billing screws the guy in the hospital.”

    I’m only familiar with Florida, but insured patients with a legit emergency can’t be punished for seeking care at an out of network ER. Similarly, the patient who has no choice as to who is caring for them (like the surgeon on call, radiologist/pathologist/anesthesiologist involved in care, etc.) is held harmless in disputes over usual and customary charges. The physician can’t go after the patient, but the insurer (after in network deductibles and coinsurance is met) must pay the physician’s usual, customary, and reasonable charges.

    Are charges the amount billed to the patient/insurer without any discounts? Or are charges the amount actually paid to the provider after network reductions?

    Defining UCR charges is where the battle lines will be drawn between insurers/consumers vs. providers (hospitals and docs).

    #225640 Reply
    Avatar southernerdoc
    Participant
    Status: Physician
    Posts: 79
    Joined: 03/10/2019

    Why would you base your reimbursement on Medicare rates when they are set based arbitrarily without reason and pay below normal market share?

    Click to expand…

    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.

     

    Click to expand…

    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).

    #226002 Reply
    q-school q-school
    Participant
    Status: Physician
    Posts: 2641
    Joined: 05/07/2017

    Why would you base your reimbursement on Medicare rates when they are set based arbitrarily without reason and pay below normal market share?

    Click to expand…

    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.

     

    Click to expand…

    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).

    Click to expand…

    thanks for responding.  it’s early so i am a bit muddled.  just so i understand, who are you negotiating RVUs with?  every single insurer?  they use RVU’s instead of $ now in your location?

     

    #226051 Reply
    Avatar Mcnamara
    Participant
    Status: Physician
    Posts: 1
    Joined: 08/11/2019

    This thread needs to be bumped… if there’s another one on the topic I missed, please do direct me to it.

    You have threads on the front page with people crying about Ally dropping their interest rates. Meanwhile this is a legitimate threat to our income and what… barely two pages of discussion?

    #238137 Reply

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