General I don’t get in and out of network insurance coverage

Chew Toy McCoy

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I know being able to keep your doctor is a big deal to some people. I like my doctor and as a bonus her age says she should be around long after I take a dirt nap (my last 2 doctors retired), but if I lost her due to insurance coverage changes it wouldn’t be the end of the world and I wouldn’t assume whoever replaces her will be an incompetent monster.

But for those who this really is a big deal, I don’t understand why ALL medical practitioners aren’t required to take ALL insurance and they can’t just change prices based on some “network”. How is this even a thing? How can anybody claim they are satisfied with the system as is given this reality? Who does this setup actually benefit and what beneficial service does it provide that’s better than all providers accepting all insurance at the same prices?
 

Eric

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I know being able to keep your doctor is a big deal to some people. I like my doctor and as a bonus her age says she should be around long after I take a dirt nap (my last 2 doctors retired), but if I lost her due to insurance coverage changes it wouldn’t be the end of the world and I wouldn’t assume whoever replaces her will be an incompetent monster.

But for those who this really is a big deal, I don’t understand why ALL medical practitioners aren’t required to take ALL insurance and they can’t just change prices based on some “network”. How is this even a thing? How can anybody claim they are satisfied with the system as is given this reality? Who does this setup actually benefit and what beneficial service does it provide that’s better than all providers accepting all insurance at the same prices?
As long as medical care is for profit this will always be a problem. It's designed around the marketplace, not for the best interests of humanity and with that you have the almighty dollar dictating how will be divided up and with what doctors either accept or deny coverage from that marketplace.

It's not just Republicans either, take a look at how many politicians are in the back pockets in the industry as well, it's frankly sickening. Even Obama, with all the wind and Democrats at his back, couldn't get a single payer system passed. We'll never see fair and equitable healthcare in our lifetimes, at least not here in the US.
 

SuperMatt

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They just released info on healthcare spending for the year: $4 trillion, a new record. American GDP is $20 trillion. 20% of all money spent in America is on healthcare…? Wow, the highest in the world. We also lead the world in COVID-19 deaths, and life expectancy here is lower than many other countries that spend half (or less) than we do on healthcare per capita.

The entire system is a failure for everybody… except insurance companies, for-profit cancer centers, pharmaceutical companies, and others ”making bank” from this broken system.
 

NT1440

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They just released info on healthcare spending for the year: $4 trillion, a new record. American GDP is $20 trillion. 20% of all money spent in America is on healthcare…? Wow, the highest in the world. We also lead the world in COVID-19 deaths, and life expectancy here is lower than many other countries that spend half (or less) than we do on healthcare per capita.

The entire system is a failure for everybody… except insurance companies, for-profit cancer centers, pharmaceutical companies, and others ”making bank” from this broken system.
…so you’re saying it’s working as intended.

America is not a county, it is real estate governed by corporate profit seeking and rent seeking, with just enough of a veneer of State functions to convince the masses (via the completely corporate media apparatus) that it’s a legitimate nation.
 
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Herdfan

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I know being able to keep your doctor is a big deal to some people. I like my doctor and as a bonus her age says she should be around long after I take a dirt nap (my last 2 doctors retired), but if I lost her due to insurance coverage changes it wouldn’t be the end of the world and I wouldn’t assume whoever replaces her will be an incompetent monster.

But for those who this really is a big deal, I don’t understand why ALL medical practitioners aren’t required to take ALL insurance and they can’t just change prices based on some “network”. How is this even a thing? How can anybody claim they are satisfied with the system as is given this reality? Who does this setup actually benefit and what beneficial service does it provide that’s better than all providers accepting all insurance at the same prices?

In competitive markets, the theory is doctors agree to accept less reimbursement to be In-network. This benefits the doctors a couple of ways: 1) less fighting over bills. Since the Dr agrees to follow the insurance company standards, the insurance company will pay and 2) the network in theory brings in new patients to the doctor. The insurance company benefits by paying out below market rates for services.

In my market, BC/BS is the dominant insurer so almost every doctor is In-network.

As for why some doctors won't take some insurance, would you buy car insurance from a company that fought every claim and then wanted to pay less that what it takes to get your car fixed? Same for doctors.
 

Chew Toy McCoy

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In competitive markets, the theory is doctors agree to accept less reimbursement to be In-network. This benefits the doctors a couple of ways: 1) less fighting over bills. Since the Dr agrees to follow the insurance company standards, the insurance company will pay and 2) the network in theory brings in new patients to the doctor. The insurance company benefits by paying out below market rates for services.

In my market, BC/BS is the dominant insurer so almost every doctor is In-network.

As for why some doctors won't take some insurance, would you buy car insurance from a company that fought every claim and then wanted to pay less that what it takes to get your car fixed? Same for doctors.

So basically there’s no benefit to the patient. It’s all a bunch of backdoor maneuvers they have no control over or say in and we're just supposed to accept this.

As far as providers not wanting to work with insurance companies that have a long history of denying claims, why the hell are those insurance companies even allowed to exist? It’s like allowing a restaurant to stay open where 75% of the diners get food poisoning under some kind of “But at least these people aren’t starving” defense.
 

AG_PhamD

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I know being able to keep your doctor is a big deal to some people. I like my doctor and as a bonus her age says she should be around long after I take a dirt nap (my last 2 doctors retired), but if I lost her due to insurance coverage changes it wouldn’t be the end of the world and I wouldn’t assume whoever replaces her will be an incompetent monster.

But for those who this really is a big deal, I don’t understand why ALL medical practitioners aren’t required to take ALL insurance and they can’t just change prices based on some “network”. How is this even a thing? How can anybody claim they are satisfied with the system as is given this reality? Who does this setup actually benefit and what beneficial service does it provide that’s better than all providers accepting all insurance at the same prices?

Insurers and providers “negotiate” a contract of reimbursement based on services provided- meaning insurers basically say this is what we’re offering, take it or leave it. If the reimbursement from the insurer is too low, practitioners won’t take the deal. That’s why a lot of private practices don’t accept Medicaid, the reimbursement is substantially less (like 30-50% less). Generally those that do have lower overhead and are forced to see more patients per hour.

Another reason is that when you sign a contract insurers can make you abide by certain rules and policies. This is another reason Medicaid is avoided, they want tons of documentation and have all sorts of financial penalties built in. Some insurers are also just very hard to work with like refusing full payment, refusing claims, taking too long to pay, etc. 20% of Medicaid claims are not paid in full (4x the rate of private insurance, 3x Medicare)- which creates a lot of hassle and more staff to deal with billing.

Another reason some insurance isn’t accepted is as simple as the practice is full and can’t accommodate taking on more patients.

In that we have free enterprise in the US, I suppose that’s why providers are not forced into doing business with every insurer. If that were the case reimbursement could be whatever the insurance wanted… which would inevitably lead to government set reimbursement prices, pretty much defeat private insurance.

So basically there’s no benefit to the patient. It’s all a bunch of backdoor maneuvers they have no control over or say in and we're just supposed to accept this.
In theory being in-network means the insurance has negotiated a price that makes your healthcare less expensive. That’s how it was supposed to work when insurance was first invented. Whether those savings gets passed on to you the subscriber is a different story.

If you have a PPO or PPS plan you can use out-of-network providers, you just pay a higher price for the services. But fewer and fewer plans are PPO/PPS.

I suppose the benefit for those with good insurance is a better chance at getting into more competitive practices- those in higher demand demand higher reimbursement. Additionally, the more your insurance pays, typically the less patients need to be seen, all things equal generally resulting in a higher quality of care as more time can be devoted to each patient.

It’s worth noting however this is not just a one sided issue with insurers. Due to lower and lower reimbursement rates, hospitals have gone from independent entities to members of these massive healthcare network monopolies- or they go out of business. For example, one health network here in Massachusetts controls almost 75% or inpatient beds, thus turning the tables on the insurance to dictate reimbursement rates. If they don’t accept, their subscribers would have nowhere to get treatment. This aforementioned MA hospital network (“not for profit” btw, which means nothing) on average gets over 30% more money for the same services than less powerful hospitals in the area.
 

Chew Toy McCoy

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Insurers and providers “negotiate” a contract of reimbursement based on services provided- meaning insurers basically say this is what we’re offering, take it or leave it. If the reimbursement from the insurer is too low, practitioners won’t take the deal. That’s why a lot of private practices don’t accept Medicaid, the reimbursement is substantially less (like 30-50% less). Generally those that do have lower overhead and are forced to see more patients per hour.

Another reason is that when you sign a contract insurers can make you abide by certain rules and policies. This is another reason Medicaid is avoided, they want tons of documentation and have all sorts of financial penalties built in. Some insurers are also just very hard to work with like refusing full payment, refusing claims, taking too long to pay, etc. 20% of Medicaid claims are not paid in full (4x the rate of private insurance, 3x Medicare)- which creates a lot of hassle and more staff to deal with billing.

Another reason some insurance isn’t accepted is as simple as the practice is full and can’t accommodate taking on more patients.

In that we have free enterprise in the US, I suppose that’s why providers are not forced into doing business with every insurer. If that were the case reimbursement could be whatever the insurance wanted… which would inevitably lead to government set reimbursement prices, pretty much defeat private insurance.


In theory being in-network means the insurance has negotiated a price that makes your healthcare less expensive. That’s how it was supposed to work when insurance was first invented. Whether those savings gets passed on to you the subscriber is a different story.

If you have a PPO or PPS plan you can use out-of-network providers, you just pay a higher price for the services. But fewer and fewer plans are PPO/PPS.

I suppose the benefit for those with good insurance is a better chance at getting into more competitive practices- those in higher demand demand higher reimbursement. Additionally, the more your insurance pays, typically the less patients need to be seen, all things equal generally resulting in a higher quality of care as more time can be devoted to each patient.

It’s worth noting however this is not just a one sided issue with insurers. Due to lower and lower reimbursement rates, hospitals have gone from independent entities to members of these massive healthcare network monopolies- or they go out of business. For example, one health network here in Massachusetts controls almost 75% or inpatient beds, thus turning the tables on the insurance to dictate reimbursement rates. If they don’t accept, their subscribers would have nowhere to get treatment. This aforementioned MA hospital network (“not for profit” btw, which means nothing) on average gets over 30% more money for the same services than less powerful hospitals in the area.

Thanks for the explanation and it does make sense, but it sounds overly complicated and elitist...and then toss in profits as another motivator.

I don’t recall if I already said it in this thread, but if somebody was going to start a new country today they wouldn’t model thier healthcare system off the US. In fact it would probably quickly be removed from the list of options.
 

SuperMatt

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Thanks for the explanation and it does make sense, but it sounds overly complicated and elitist...and then toss in profits as another motivator.

I don’t recall if I already said it in this thread, but if somebody was going to start a new country today they wouldn’t model thier healthcare system off the US. In fact it would probably quickly be removed from the list of options.
Our health system is defective. The ACA was the right idea, but they watered it down to appease insurers and Republicans. Of course, every Republican refused to support it in spite of that (mainly because somebody from Hawaii dared to wear a tan suit). Upon realizing that, since Dems had the numbers to do so, they should have gone all-in on a single-payer system.

Look at how far we have fallen behind most other countries, despite being #1 (by a LOT) in money spent on healthcare.

Dems had a chance to fix this and didn’t pull it off. Republicans haven’t done ANYTHING about it, period. How is this not a more pressing concern? Do people just like dying earlier and going bankrupt over medical bills?

Granted, some of the reasons we have lower life expectancy are not just the health system. We have obesity problems, we shoot each other too much, and despite being so “rich,” we have much more poverty than other wealthy nations. But the expense of healthcare is ridiculous and should be fixed yesterday.

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AG_PhamD

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Thanks for the explanation and it does make sense, but it sounds overly complicated and elitist...and then toss in profits as another motivator.

I don’t recall if I already said it in this thread, but if somebody was going to start a new country today they wouldn’t model thier healthcare system off the US. In fact it would probably quickly be removed from the list of options.

Yeah, we’ll that’s the for profit healthcare system for you. Nothing is easy or straightforward.

It’s worth mentioning that if you’re not careful, you can actually lose money billing insurance- whether it be subpar reimbursement rates, not using optimal billing codes, etc. What you can accept widely depends on what the overhead costs are. And now practices have to hire billing specialists to deal with the complexities of insurance, which only makes things more expensive.

In fact most hospitals lose money on Medicare and Medicaid patients, often making up the difference with inflated costs to private insurance and using other profit centers. It’s a totally inefficient system.

Mental healthcare is the worst when it comes to reimbursement, which is why more and more providers are moving to private-pay and more and more programs do the same. That’s why the waiting list for psychiatrists is often months through insurance. Unfortunately the people who need the most care typically have the least resources and the access to a quality of care that’s overburdened, overwhelmingly understaffed, and underfunded.

One of the therapists that works for me used to have a caseload of 120+ patients with 40-50 sessions per week, working at a primarily Medicaid program. How good can even the best therapist possibly be if she has to keep track of 120 clients at once- and basically only enough room to see most clients 1x per month. At that point you’re really just pretending you have a relationship with the patient.

And don’t get me started about pharmaceutical coverage and the ridiculous, inadequate reimbursement system based on a game of smoke and mirrors and middlemen.

Switching to universal healthcare would definitely make things a lot easier, but I’m not sure how that could even occur at this point with a medical-insurance-pharma-biotech industry so tightly immeshed and financially dependent with each other.

If there’s one benefit to our healthcare system, the ridiculous amount of money that flows through it has enabled a tremendous amount of innovation that would otherwise be much more difficult to fund.

At the very least, there is a lot that could be done to reform the inefficient healthcare system we have. I don’t expect much change to happen unfortunately. Whatever changes politicians speak of either never happen, are designed to have no significant effect, and all too often mysteriously, end up benefiting the insurance and pharma industry.
 

Chew Toy McCoy

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Yeah, we’ll that’s the for profit healthcare system for you. Nothing is easy or straightforward.

It’s worth mentioning that if you’re not careful, you can actually lose money billing insurance- whether it be subpar reimbursement rates, not using optimal billing codes, etc. What you can accept widely depends on what the overhead costs are. And now practices have to hire billing specialists to deal with the complexities of insurance, which only makes things more expensive.

In fact most hospitals lose money on Medicare and Medicaid patients, often making up the difference with inflated costs to private insurance and using other profit centers. It’s a totally inefficient system.

Mental healthcare is the worst when it comes to reimbursement, which is why more and more providers are moving to private-pay and more and more programs do the same. That’s why the waiting list for psychiatrists is often months through insurance. Unfortunately the people who need the most care typically have the least resources and the access to a quality of care that’s overburdened, overwhelmingly understaffed, and underfunded.

One of the therapists that works for me used to have a caseload of 120+ patients with 40-50 sessions per week, working at a primarily Medicaid program. How good can even the best therapist possibly be if she has to keep track of 120 clients at once- and basically only enough room to see most clients 1x per month. At that point you’re really just pretending you have a relationship with the patient.

And don’t get me started about pharmaceutical coverage and the ridiculous, inadequate reimbursement system based on a game of smoke and mirrors and middlemen.

Switching to universal healthcare would definitely make things a lot easier, but I’m not sure how that could even occur at this point with a medical-insurance-pharma-biotech industry so tightly immeshed and financially dependent with each other.

If there’s one benefit to our healthcare system, the ridiculous amount of money that flows through it has enabled a tremendous amount of innovation that would otherwise be much more difficult to fund.

At the very least, there is a lot that could be done to reform the inefficient healthcare system we have. I don’t expect much change to happen unfortunately. Whatever changes politicians speak of either never happen, are designed to have no significant effect, and all too often mysteriously, end up benefiting the insurance and pharma industry.

I’m sure I’m oversimplifying things here but I wish we could limit the amount of profiteering you can do on things like healthcare, housing, and war. I know FDR attempted an economic bill of rights but he died shortly after he announced it and unsurprisingly nobody championed it from there.
 

Herdfan

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I’m sure I’m oversimplifying things here but I wish we could limit the amount of profiteering you can do on things like healthcare,

I would be happy if hospitals stopped spending millions on architects who design these beautiful buildings that add zero to patient care. Why does a hospital need a huge all glass entry that rivals a Vegas hotel?
 

AG_PhamD

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I’m sure I’m oversimplifying things here but I wish we could limit the amount of profiteering you can do on things like healthcare, housing, and war. I know FDR attempted an economic bill of rights but he died shortly after he announced it and unsurprisingly nobody championed it from there.

The biggest driver of healthcare costs are these large hospital networks, which are becoming increasingly consolidated- as I mentioned before. They can monopolize markets and then dictate their reimbursement rates from private insurance. Since Medicare and Medicaid sets their own rates, it’s often insufficient, so the private insurance gets charged to cover this deficit as well as uninsured patterns.

And hospital networks are buying up private outpatient practices, which usually increases the price of services to cover the hospitals administration overhead. This also allows the doctors to refer patients back to the hospital for services typically provided by 3rd parties, like diagnostic imagining and blood work- and the hospital charges substantially more (2x the price of an MRI).

And private insurers don’t necessarily care what the reimbursement is- especially when it comes to these monolithic hospital networks. They can just charge higher rates to the patients. Considering they earn a percentage of the cost, increased prices can actually benefit them.

Doctors in the US also get paid significantly more than anywhere else in the world. This is largely because of the significant shortage we have- which is basically by design. On top of it, unlike most countries, the majority of US doctors specialize (which benefits teaching hospitals), masking them have to get paid more.

Additionally, malpractice litigation is insane in the US compared to other counties, most of whom are insured through the government health system and there are set legal limits of $300-400,000 for damages. And such cases are not nearly as prevalent. Meanwhile in the US people are constantly suing and able to win millions in damages. Therefore the insurance overhead is far higher. Obstetrician malpractice coverage is apparently as high as $150k/yr.

Both hospitals and private insurance, but also Medicare/medicaid, have created such complex systems that the amount of staff required for administration becomes a costly burden of its own. JAMA had an article as while back suggesting as much as 15-25% of healthcare costs are related to administrative overhead. Hospitals having departments for optimizing the claims to insurers to maximize reimbursement based on the specific plans (one of thousands) way of doing things. And whether it’s an inpatient treatment or a prescription to be filled, practically everything requires prior authorization which is time consuming and slows the speed treatment can occur.

The cost of pharmaceuticals is obviously a driver of costs and accounts for about 15% of spending. There’s a lot of problems here from the pharmaceutical companies, to pharmacy benefit managers, to retail pharmacy monopolies, to zero transparency on what drugs actually cost, etc. And an unfortunate reality is to some extent we pay more because other countries pay less. But the way our healthcare system assessed the value of drugs is also often quite flawed.
 
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