Out of Network, Out of Luck

As we behold the continued wonders of ObamaCare, we receive another reminder of the president’s empty promise, “If you like your doctor, you can keep your doctor.” The New York Times, late to the party as usual, observed this week, “No matter what kind of health plan consumers choose, they will find fewer doctors and hospitals in their network – or pay much more for the privilege of going to any provider they want.” What a surprise – stop the presses!

Insurance networks are common features of many plans. The network represents a group of physicians, hospitals, and other providers that contract with an insurance plan to provide specified medical care at set fees. As insurer United Health Care describes it, “[r]eceive quality care at reduced costs because our network providers have agreed to lower fees for covered expenses.” For the providers, this agreement represents a tradeoff – access to patients, but for lower payment. For the insurance companies, it’s a way to cut costs. These types of business arrangements are common. Businesses that join the AARP network agree to provide discounts to AARP members in exchange for access to AARP members.

In health care, access to patients is paramount for providers, and this access is through insurance networks. While AARP members won’t go bankrupt if they don’t take advantage of their half-price movie theater tickets or two-for-one lunch deals, going out of network for heart surgery or cancer care is another matter. According to United, “[t]he out-of-network provider's actual charge [may be] billed to the member.” Meaning that the patient could be on the hook for the entire cost of care.

Good piece, but what the author fails to identify is that the leftists have INTENTIONALLY supported this. These defects are going to be exactly what is needed to push the solution (perhaps incrementally) to a single payer insurance scheme.

And when more physicians in private practice refuse to accept the single payer government system, that will be the excuse used to mandate nationalization of all health care...linking providers' licenses to being employed by the nationalized health care employer.

The only true solution set is to completely phase out third party insurance and actually use a free market system. That may mean that some people may not be able to afford the latest and greatest therapeutic solutions. But can everybody afford to buy a Maserati? Can everybody afford to shop at Saks?

“Meaning that the patient could be on the hook for the entire cost of care”.

It could also mean a couple of other relevant points.

Your doctor may not be part of the network your insurance carrier has you in. You lose, because they can refuse to cover you.

Your cost may actually be less out of network, but that isn’t mentioned.

Competition in health care is a bad thing when one considers a network. You aren’t supposed to go outside for any reason. Just ask your network provider or question any Hospital that is part of a network and I’m betting they all have a network,and an insurance plan.

There will be an initiative on the Ballot in November that will allow folks not to be corraled by a particular network and is usually called an any willing provider bill. Such bills are very difficult to get past the Hospital and Insurance Lobbies in the Legislature, but the people provided the petition signatures, which is why it will be a ballot initiative.

If you have been following the news you will see that there is a move afoot to have all doctors inside a network and making it very difficult for the independent doctor or small clinic doctor, or private practice doc to be competitive with the large Hospital provider. Get them all in a network and you control the business.

This move to spread the wealth through private enterprise and competition, will help to reduce cost, if it takes off, removing the stranglehold the insurance and Hospital industry has on the medical field. Maybe that’s a bit harsh, but others are sure to weigh in.

“Your cost may actually be less out of network, but that isn’t mentioned.”

You are entirely correct. As being one who is quite healthy, my need for anything other than catastrophic insurance is not worth the regular expense. My GP only charges me $90 per visit if I pay cash. To get added to my wife’s insurance plan my portion is over $730 a month. I may go to see the doctor for a physical but that is it.

So recently I had surgery for a hernia that required mesh. I went to the hospital connected surgeon who did my insurance paid umbilical hernia at the end of 2006 for a consultation. Just that visit cost me $318 and that was his cash price for what amounted a 5 minute consultation. Nothing other than his opinion that I indeed had a hernia above the umbilical. When I questioned why so much for a simple visit, they said I was a new patient. I was told that if I did not have another surgery in three years that automatically made me a new patient. but, they had all of my information at hand from the previous procedure.

Next came the scheduling person who gave me the procedure codes and if paying with insurance, the surgeon’s fees would have been about $3800, cash at $2400. Then I took those same codes to the hospital for their estimates and was told the facility fee would be in the neighborhood of $35,000 with insurance payment and $12,200 with cash. I never got to the estimate for the anesthesiologist.

So, I just happened to drive by an ambulatory surgical center and decided to go-a-callin’. I contacted three different ones and they referred me to surgeons approved to practice there who were also on at some hospitals as well.

After doing the homework on each and also checking into the surgeons, I came up to what I felt was the way to go. Since I already had the codes, I was able to get estimates for the facility fees.

I found a surgeon that ironically was a member of the same surgical group as the first surgeon. I was very impressed with his consultation as he took the time to explain the procedure in detail and I left his office very high in confidence, especially only having to pay $160 for that visit.

The bottom line is that if I were to have used insurance that would have cost me over $8700/yr, I had the entire procedure done for $4200 and that included the charges for the anesthesiologist, surgeon and facility fee. The estimate cost of the hospital with insurance paying would have been near $50,000. BTW, I have only been to a doctor maybe four or five times since that umbilical procedure, since the end of 2006.

So in my view, if we depend on the insurance companies and their monthly charges, we are still paying the bill eventually for this huge discrepancy. Mostly because of the rules and regulations the insurance industry has to operate under from government regulations. Eventually, I would summarize the insurance lobbyists and our corrupt government have conspired to break the system so they alone could be depended upon to be the only ones to fix it. Nothing else explains where we are today.

Crony capitalism applied to delivery of medical services.

When access to the official market is too difficult, then the black market becomes the trading center.

When the penalties and taxes become too onerous, then not merely tax avoidance, but outright tax evasion and fugitive status make perfect sense, even if a gamble.

What was the point of MANDATING purchase of “health insurance”, if no services are to be delivered under its conditions? This is like merchants paying “protection money” to the Mafia, so “nuthin’ BAD happens, capish?”

The left historically deals with this by outlawing Maseratis and high-priced retail venues.

If the latest and best therapeutic solutions are not freely available to everyone, those solutions will be available to no one. The press will co-operate by not reporting any instance where an elite receives top tier care and will instead ascribe the obviously superior health and survival of the politically-connected wealthy to their ingestion of kale and practice of meditation.

Some brave practitioners may try to buck the system, but control of a clinician’s license is a powerful weapon. Already, refusal to participate in the government insurance scheme results in loss of hospital admitting privileges. At some point, the *renegade* clinicians will not even be able to actively refer patients to others who retain those admitting privileges. The risk to those within the system will be too great.

I’m not sure we can even foresee how horrific this can become.

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