Menu

Proposed federal bills limiting OON billing

Home General/Welcome Proposed federal bills limiting OON billing

  • Avatar jhwkr542 
    Participant
    Status: Physician
    Posts: 1316
    Joined: 02/15/2016

    Yes, that’s an issue but not the main issue for this bill. It’s hard to have good faith negotiations for fair market rates when failing to reach a deal advantages one party so much more than the other.

    #240173 Reply
    Avatar Tim 
    Participant
    Status: Accountant
    Posts: 3093
    Joined: 09/18/2018

    “That’s the whole point. The insurance and government both want to drive reimbursements down.”

    Both have an army of administrators, lobbyists, and attorneys on the payroll to “prove” the Doc needs to charge 2% less. Just work faster!

    #240260 Reply
    Avatar nephron 
    Participant
    Status: Physician
    Posts: 227
    Joined: 05/09/2019

    balance billing is another symptom of a healthcare “marketplace” that does not work.   The dialysis units that I round in seem to purposely stay “out of network” for insurance companies so that when patients do end up there because there is not another more local dialysis unit, the unit can charge exorbitant, much higher fees then the in-network fees which the insurance companies offer.   The in-network fees are always higher then the medicare and medicaid fees that the units accept, but the dialysis units justify the practice by claiming that they need the private insurers to pay much higher fees to make up for their losses that they assume when they take medicare and medicaid patients.  This is true to a degree, medicare and obviously medicaid do not reimburse enough to keep the staff paid/electricity running/ medication costs etc, but obviously, a lot of the units generate a healthy profit from this practice.  Facility fees are easier to figure out too- you can have an accountant determine the cost of paying staff/meds/machines, divide it by the number of patients, and figure out an actual cost.   Nobody wants to go by this number though because the government doesn’t want to have to pay what things cost, the dialysis companies are for profit and want to generate a profit, and insurance companies are kind of stuck because they have to provide treatments for patients.  I imagine that is probably why you have all these insurance-provider hospital conglomerates entering the market.   I imagine that it is even harder to determine the  cost surgical or anesthesia fees which are arbitrary and not based on any formula other then what some committee in medicare decides annually.

    #240269 Reply
    Liked by Zaphod
    Avatar wcinewbie 
    Participant
    Status: Physician
    Posts: 91
    Joined: 09/30/2017

    That doesnt quite make sense. When they are out of network, it is usually patients who pay those higher fees. And again, why do we keep hearing about all these entities that claim they have to make up for low medicare reimbursements when many physicians are being paid in network rates that are lower than Medicare rates??

    #240324 Reply
    Avatar jacoavlu 
    Moderator
    Status: Physician, Small Business Owner
    Posts: 2382
    Joined: 03/01/2018

    Are “many” physicians are being paid in network rates that are lower than Medicare rates?

    I know it happens but this blows my mind.

    The Finance Buff's solo 401k contribution spreadsheet: https://goo.gl/6cZKVA

    #240327 Reply
    Liked by okayplayer
    Avatar loeffy 
    Participant
    Status: Physician
    Posts: 62
    Joined: 08/28/2016

    I’m not sure about many.  But I have known doctors to mention that about their reimbursements.  I helped a MD family member in their office in college and did some billing for them, and their private reimbursements were about equal to medicare.  InvestingDoc commented about this issue as well.  In all these cases these are small/solo practices.

    #240649 Reply
    Avatar Radonlake 
    Participant
    Status: Physician
    Posts: 38
    Joined: 01/24/2019

    We had a recent negotiation with a large insurer and the initial offer was less than medicare rates for commercial (and of course medicaid and their medicare advantage type product) for our small radiologist group. Our billing company negotiated hard and we got I think 8% and 15% over medicare. The billing company is in multiple states and also said that below medicare is more frequent now than we were aware of – and concerned them in addition to the looming OON disaster.

    #240712 Reply
    Avatar jacoavlu 
    Moderator
    Status: Physician, Small Business Owner
    Posts: 2382
    Joined: 03/01/2018

    We had a recent negotiation with a large insurer and the initial offer was less than medicare rates for commercial (and of course medicaid and their medicare advantage type product) for our small radiologist group. Our billing company negotiated hard and we got I think 8% and 15% over medicare. The billing company is in multiple states and also said that below medicare is more frequent now than we were aware of – and concerned them in addition to the looming OON disaster.

    Click to expand…

    Ouch. Was this an initial contract with this payer? If not,was this a large cut vs your prior agreement? Multi year contract?

    The Finance Buff's solo 401k contribution spreadsheet: https://goo.gl/6cZKVA

    #240715 Reply
    Avatar Radonlake 
    Participant
    Status: Physician
    Posts: 38
    Joined: 01/24/2019

    Renegotiation for adding another physician (me 😉 to the contract which they claimed could not be added to the old contract but I also could not get a separate new contract because I bill with the group TIN. Big decrease from the contract my partners had – they used adding me as an excuse to renegotiate because I should have been able to join (lots of prior partners have joined and left under same old contract) but well…. The group has been contracted with them since >20 years I believe.

    #240720 Reply
    Avatar okayplayer 
    Participant
    Status: Physician
    Posts: 124
    Joined: 05/25/2016
    #245868 Reply
    Liked by Tim
    Avatar G 
    Participant
    Status: Physician, Small Business Owner
    Posts: 1800
    Joined: 01/08/2016

    Renegotiation for adding another physician (me 😉 to the contract which they claimed could not be added to the old contract but I also could not get a separate new contract because I bill with the group TIN. Big decrease from the contract my partners had – they used adding me as an excuse to renegotiate because I should have been able to join (lots of prior partners have joined and left under same old contract) but well…. The group has been contracted with them since >20 years I believe.

    Click to expand…

    wow, I missed this discussion last time.  sounds like Big Insurance shenanigans.  we have added an average of about 2 docs/yr…can you imagine the chaos if this meant renegotiation every time with every contract.

    you might sniff around via your medical society and see how many other groups got screwed…but of course Big Insurance knows that they can (usually) wear you down with lawyers fees….

    #245906 Reply

Reply To: Proposed federal bills limiting OON billing

In case of a glitch or error, please save your text elsewhere, clear browser cache, close browser, open browser and refresh the page.

Notifications Mark all as read  |  Clear