Deal banning surprise medical bills 

Doctor’s have established fees, they join a network and accept condiderably lower fees OR they don’t join and charge their normal fee paid in part or whole by the patient.

Presumably the arbitration called for in this legislation will result in a final payment above the network fee and below the established fee.

So why would any doctor join a network if they can receive a higher payment by not joining?

The deal — by Health, Education, Labor and Pensions Committee Chairman Lamar Alexander, R-Tenn.; Energy and Commerce Committee Chairman Frank Pallone Jr., D-N.J.; and ranking member Rep. Greg Walden, R-Ore. — would prohibit health care providers from sending so-called “surprise medical bills” to patients that are inadvertently treated by an out-of-network doctor.

The lawmakers have not yet released the text of the agreement. The three said in a statement that insurance companies and providers would determine payment through a new dispute resolution system that includes arbitration.

The statement did not specify how arbitration, which has been the primary flashpoint in the debate, would be used.

Source: Deal banning surprise medical bills also ups tobacco purchase age to 21

3 comments

  1. I worked for Blue Cross many years ago. It was standard practice back then that if the patient duly chose a network doctor and network hospital and the patient had no choice/control over the network doctor and/or network hospital using out-of-network providers like anesthesiologists, radiologists and pathologists. Those out-of-network provider fees were allowed in full and paid at network benefits. Unfortunately, sometimes the computer claim processing system did not automatically do that. I personally adjusted many claims to pay that way once it was brought to our attention by the member or provider.

    There was a similar rule for out-of-network health care rendered within 48 hours of an accident and/or medical emergency. I adjusted many such out-of-network provider claims to pay billed charge at network beneifts.

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  2. Not knowing what the bill actually says, my issue is that if you go to an in network hospital, then you should not be billed by non-network “subcontractors”, that is doctors, x-ray department, etc.. The reason being is that you don’t have a choice who the hospital chooses to allow to treat you. You just assume that you followed your insurance requirements and went to an in network facility. While you are on the operating table you don’t get a chance to ask each doctor or tech if they take your insurance.

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  3. Mr. Quinn:

    A couple of comments …

    1.) You are presuming that “in-network” physicians and hospitals are negotiating lower than standard fees with insurance providers. I don’t accept that presumption at all. Insurance providers have no incentive whatsoever to negotiate LOWER reimbursement rates – quite the opposite in fact. Insurers only have an incentive to “lock in” KNOWN reimbursement rates with physicians and other health care providers, and that only for a one year period – until they can demand higher premiums. They simply have to have “known” rates of payments, not lower rates.

    2.) Physicians and other health care providers join insurance “networks” NOT to get higher (or lower) fees, but to ensure a steady stream of clientele. THAT is the real reason insurers are loathe to pay either patients OR out-of-network providers – it “violates” their commitment to their “in-network” providers for supplying the “steady stream” of patients.
    Doubt that? Then why would ANY insurer not be more than willing to re-imburse a Patient (directly) when they get out-of-network care, and reimburse for exactly the amount they would have paid for the exact same “in-network” care?

    3.) The reason “arbitration” is a sticking point, is that both insurers AND health care providers have to make certain that their fee structures and billing/reimbursement practices are not subject to Court and Jury scrutiny. The “arbitration” scheme is the mechanism used to keep providers, insurers AND patients out of the Court system – where current fee structures/billing practices wouldn’t stand up well to Jury scrutiny.

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