Balance billing? What’s new?
Same old game, same old players. For decades it was typical for physicians will little or no contact with patients who also enjoyed high fees to not participate in any insurance, even long before participation was called “networks.”
As noted below we are mostly talking about anesthesiology, pathologists, radiologists, and assistant surgeon. Based on my experience I would add ultra specialists. I often negotiation on behalf of employees in these fee disputes.
We need to ask how any physician can justify charging significantly more than his or her peers? On the other hand, there are some physicians who don’t want to deal with the complexities of participation, but voluntarily accept the network fee.
The problem has grown worse with more restrictive networks and high deductible plans.
At least in theory physicians agree to a network fee to retain or gain patients. That is probably more theory than fact, but the advantage for physicians is a guaranteed payment with a bit less patient billing hassle. For the specialties listed above gaining or losing patients is not an issue. I know a radiologist who never leaves his home office, but simply reads the studies online.
But what is the real solution? We seem to think that protecting the patient is primary, but any negotiated or arbitrated fee higher than the standard network fee means higher premiums for all insured, the employer or plan participants.
There is one solution. Every physician in an area, even within a hospital, must accept as payment no more than the average negotiated fee for the same service and specialty. This will encourage participation if the physician can justify a higher than average negotiated fee.
An alternative is simply to follow the Medicare model. That is, no physician can bill more than a fixed percentage above the allowed participation fee. 15% in the case of Medicare. There is the risk of declining participation, but it has not proved to be a problem with Medicare.
The individual dispute resolution process will prove too cumbersome and, of course, adds more cost to the system.
Patients would save billions of dollars a year if medical specialists were not allowed to bill out-of-network rates.
An analysis of 2015 data obtained from a “large commercial insurer” showed that a significant percentage of medical services were billed out-of-network, including 11.8 percent of anesthesiology care, 12.3 percent for care involving a pathologist, 5.6 percent of claims for radiologists, and 11.3 percent of cases involving an assistant surgeon.
According to the research, reported earlier this week in Health Affairs, if out-of-network billing were eliminated, overall payments to doctors would decrease by 13.4 percent and patient spending on health care would drop 3.4 percent, or by roughly $40 billion annually.