Questions about reimbursement for doctors from insurance companies

[herewego]

Please forgive my ignorance on the matter, I'm just now trying to research all the different aspects of how doctors are paid and how insurance works, hmos and ppos etc. So any help in my questions/clarifications would be appreciated.

So from what I gather, if a patient comes in with insurance..after seeing the patient the doctor writes down what was done and what procedures etc the doctor is billing the patient for, and then the insurance companies decides how much to reimburse the doctor?

Is this correct? If not please clarify. And is this for HMOs and PPOs alike? or does it depend on the specific situation?

Also, can someone please clarify the issue of reduced reimbursements to doctors? I thought it was just for medicare patients? So how does that hurt doctors who just take people with insurance/pay cash.

EDIT: another question: so insurance companies are charging ridiculous prices to those insured, and not reimbursing doctors well? Is this part of the basis for doctors leaving medicine? They don't make enough to cover overhead/malpractice?

Again, any help would be appreciated.

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[TheMightySmiter]

If a patient has insurance, the physician's office will collect any co-pay as specified on the card and make a copy of the card to have all the info. The doctor will fill out a billing sheet after seeing the patient with any diagnoses or extra procedures that were done. Through a rather headache-y process, this form will eventually go to the respective insurance company who will reimburse the doctor. If the reimbursement is less than the actual cost, the doctor's office will bill the patient for the rest (someone correct me if I'm wrong and if it's the insurance company that bills, but I think it's the doctor/hospital). As far as I know this is true for both HMOs and PPOs. The major difference between these two is how the patient goes about choosing a doctor.

A reimbursement to a doctor will be reduced if the insurance company denies any part of the patient's claim. I think that's what you meant by asking? Also, most doctors who "contract" with insurance companies will agree to lower prices than normal for patients who have that insurance company. Doesn't affect the patient's co-pay, but the insurance companies end up paying less. Insurance companies regularly deny patient claims for whatever bull**** reason they can come up with, and in that case will send less of a reimbursement to the doctor. It's then up to the physician to bill the patient for the remaining amount.

Also, insurance companies are notoriously terrible at sending reimbursements and processing claims on time. The clinic where I volunteer at had to recently drop a major insurance company from the ones they accept because it was just not reimbursing claims. Interestingly enough, Medicare tends to be the quickest and most reliable provider when it comes to reimbursements.

Hope that helps!

 

[herewego]

Fantastic response! I really appreciate it, it answered a lot of my questions.

If you don't mind, I have some follow questions to your responses.

1)So where does the whole issue of doctors not being able to cover their overhead prices if they have a practice? If the insurance companies doesn't give the full reimbursement, then shouldn't the rest of the cost be covered by the patient and so the doctor should, one way or another get paid? Is that just an issue with medicare patients who probably can't afford to pay?