Blindsided
I really don’t understand how these companies get away with this stuff. Charging $1300 for a patient with a lac you call a plastic surgeon to fix or a corneal abrasion is just insane.
Makes us all look bad.
Yes, the optics make “us all look bad,” especially if dishonest, biased or incompetent journalists don’t give the full story. And yes, there are sleazy docs and groups that abuse the system. And yes, the system is messed up.
But why are you letting the insurance companies off the hook, as if they’re so innocent?
In these scenarios, where docs go ‘out of network,’ often the insurance companies are either not paying competitive enough rates to get the docs to be in their networks, or they’re using sleazy, dirty and borderline illegal tactics. So, the docs go out of network, which can be a risk, in that you may lose patients with those insurances you don’t play with. Other times it might pay off. And on the occasion the doc gets a few extra dollars, by happenstance, the doc is the bad guy?
If you know how the game is played, it’s not so simple.
You’re asking the doctors involved, when offered the choice or “X” dollars for a certain amount of work, versus “X +” dollars for a certain amount of work, to choose the lesser, out of the goodness of their own heart.
Who in their right mind, would choose the lesser? Would you?
No one on their right mind, would do so, when faced with this choice. If fact, you and all of us on this board, face this choice, everyday, whether you choose to be aware of it or not. You can either get paid your current salary for the work you do. Or, out of the goodness of your heart, you can go to your employer and say, “I know I’m making ‘X,’ but I think it’s too much. It’s not fair to others. It’s not fair to the patients. It’s not fair to the system. I’ll work for ‘X minus 10%.’”
But you’re not going to do that.
When you’re in EM, you don’t always see the ugly, dirty games being played behind the scenes by the government payers and insurance companies.
I’ve had insurance companies give written pre-approval for procedures. Then once done and billed, they stiff me. They don’t pay a damn thing and deny non-experimental treatment as ‘experimental,’ or give no reason at all, even with written pre-approval from their own staff.
Am I then the bad guy for dropping out of their network?
Or Medicaid. When a patient has Medicaid as a secondary, they’re responsible for 20% of the patient’s bills, by law, as is any insurance company. But when the bill goes out, you know what Medicaid in my state pays when their a secondary insurance?
Zero dollars. That’s right, zero dollars.
And you know what the reason is?
The reason given is, “-—k you, we’re broke. Deal with it.” But they’re not broke. I haven’t seen Medicaid shutter their doors yet, and don’t expect them too, anytime soon.
Is the doc the bad guy, for dropping out of Medicaid’s network or for declining their patients?
There’s another insurance company in my area that more than once, has required all patients get physical therapy before MRIs or injections. Then, when physical therapy was ordered, the
deny the physical therapy because the patient’s had ‘too much physical therapy,’ which was all unnecessary but all of which was required by
them.
I had another insurance company that would approve procedures, pay for them, then a few weeks later send a letter demanding immediate refund of payment (no reason given) under the threat that if I didn’t send the money back, I’d be immediately kicked out of network. They did this multiple times involving thousands of dollars. When we appealed this, to try to get them money back, again, they said it would be a 6 month review process. When I called my group’s billing people, complaining that this seemed illegal and we should fight it, they said, “Our only recourse is to appeal it, hope they give the money back. If they don’t, you’re screwed. You’re only recourse is to drop out of their network.”
Some of what these insurance companies do, borders on being criminal. And don’t think they don’t screw their patients, too. They do, all the time. They advertise that they cover a service. They then take the patient’s money and when the request a service they deny it, or create hoops to jump through that are so burdensome they know the patient never can meet them. So, do they give the patient their premium money back?
No.
Just be aware, this is a complex and dirty game, and neither the insurance companies nor the government payers are innocent in any of it.
