5 ms·

Out-of-network was always just a sketchy way for insurance to avoid paying what they should have paid. Let's say you get a hypothetical procedure. Insurance ha

Out-of-network was always just a sketchy way for insurance to avoid paying what they should have paid. Let's say you get a hypothetical procedure. Insurance has already agreed to pay in-network providers between $1-3K for this procedure. But you got this procedure out-of-network. Why is insurance's liability suddenly $0 instead of whatever the lowest in-network fee schedule would be ($1K in this example)? See I can understand insurance not wanting to foot substantially higher bills than in-network providers charge, but I cannot understand why it drops to $0 reimbursed when you leave network. It seems like an immoral "gotcha." But then again I'd like to see insurance discounts/agreements banned. Make everything and nothing in-network and also normalize the insured/uninsured prices. No more "$100 for a band-aid, -$99 discount" shenanigans. Obviously single-payer would be better yet still, but if we must keep using this broken private employer-linked insurer system let us at least keep band-aid fixing it until we can get enough political support to scrap it.

deregulateMed 5y ago
Just a note, it's possible to lose money accepting some Medicaid insurances. Specifically if you need to hire a translator. $40/hr payout for physical therapy + translator contactor.
bradstewart 5y ago
Totally agreed. My favorite is when you add this scenario to physically being somewhere without any in-network doctors. I cut my hand open climbing in northern New Mexico, bandaids and gauze weren't stopping the bleeding, so I went to the nearest town clinic/urgent care. Ultimately got 8 stitches. My insurance denied (almost) everything. They would later explain that I was supposed to drive myself several hours to Albuquerque to get my hand looked at instead. I say almost because the covered $70 for the lidocaine shot, but literally nothing else. Why they deemed the lidocaine necessary but not the stitches could not be explained. Clearly they had a way to pay the clinic, so wasn't that. Another whacky thing I discovered: the insurance company gets to decide how much, if any, of your uncovered, out-of-pocket bill counts towards your deductible. In this case they deemed $109 of $832 to be the right number, with no explanation as to how they arrived at that sum.
- jrs235 5y ago
  Should probably have gone to an ER. Emergencies are easier to argue and appeal. "Urgent" (yet less costly) and they assume you still could have waited... it wasn't an emergency yet. I hate our insurance/medical payment/determination system. It's a joke.
  - vinceguidry 5y ago
    I went to an in-network urgent care for a particularly painful pinched nerve and got worthless drugs, and the uncovered part of the bill came out more than the covered part. Next time I'll just suffer at home and hope I don't die. It'll amount to the same result.
  - Workaccount2 5y ago
    Given the location and possible severity, the only viable way to an emergency room might have been a helicopter. Which insurance almost certainly would not cover. So the insurance is saying "If you paid $80,000 for a medevac, we would have covered your hospital bill".
    - FireBeyond 5y ago
      Hell, a few years ago UHC made the news because they were denying coverage for Flight EMS from serious car accidents due to "lack of pre-authorization".
  - ceejayoz 5y ago
    They're looking at clamping down on that, too. https://arstechnica.com/science/2021/06/biggest-health-insurer-plans-to-deny-er-bills-if-it-doubts-you-had-an-emergency/ https://arstechnica.com/science/2021/06/biggest-health-insur... > Doctors and hospitals are condemning plans by UnitedHealthcare—the country’s largest health insurance company—to retroactively deny emergency medical care coverage to members if UHC decides the reason for the emergency medical care wasn’t actually an emergency.
    - sidewndr46 5y ago
jstrom 5y ago
You can theory-craft a non-malicious justification: Insurance trusts Dr. Hibbert will perform the procedure without complications and has negotiated a fixed price of $1K. Insurance doesn't trust Dr. Nick and believes any procedure he performs will result in a second claim later to set things right. Insurance strongly wants you to chose Dr. Hibbert and the only leverage they have is to refuse to pay for Dr. Nick should you go with him. Not sure how plausible that is though--I suppose they could data-mine frequency of follow-up treatment required per doctor--but I've never observed in network/out of network to correspond to a meaningful metric (our local dentist recommended by all the dental specialists around doesn't deal with any insurance companies, while the in-network dentist is pretty clearly padding their work)
- inetknght 5y ago
  Why doesn't the insurance company trust Dr. Nick? If there's reason to not trust Dr. Nick, then surely the insurance company must disclose it. If there's reason to not trust Dr. Nick, then surely Dr. Nick would have trouble maintaining a medical license. If there's reason to not trust Dr. Nick then surely Dr. Nick's own malpractice insurance would become too onerous for him to keep. No, this smells exactly like what @Someone1234 stated: > Out-of-network was always just a sketchy way for insurance to avoid paying what they should have paid.
  - jrs235 5y ago
    Sometimes the trust issue is more about fraudulent claims than one's ability to practice medicine...
    - inetknght 5y ago
      > If there's reason to not trust Dr. Nick, then surely the insurance company must disclose it. That should include "we think Dr. Nick makes fraudulent claims"
    - jakelazaroff 5y ago
      Then why is he still in business? If he's committing insurance fraud, then the insurance company should work with regulators to stop and potentially prosecute him. The onus to prevent fraud should not be on me as a patient.
toast0 5y ago
It kind of depends on the network. For a real owned and operated HMO where every provider in the network buildings and offices is an employee of the network (or under contract as a network provider), in-network only (for non-emergency services) makes a lot of sense to control costs, make staffing predictable, ensure consistency of care, etc. As an insured, you go to one building and get everything taken covered. If you want to go out of network for something, you need a good reason or be willing to pay for the whole thing. When it's a third party HMO network and you've got stuff like a medical office where only some doctors are in network and others aren't, so if your doctor is behind or out sick and you're offered to see another doctor in the interest of time and then you've seen an out of network doctor, that's a totally different deal. Then you've got things like in-office X-ray analyzed by an off-site radiologist whose identity and network status wasn't known before hand. I'd like to see non-emergency medicine take up the same kind of quoting requirements as auto repair. You can't always stop a procedure to update the quote, so provide several quotes for the likely outcomes.
crazygringo 5y ago
I'm not defending it, but there is actually a logical justification here -- it's not just insurance companies being evil. When insurance companies sign up doctors to their network, doctors agree to lower fees (lower profit) but expect to make it up in volume, because the health plan will send them more patients. But that only works if patients are made to stay in-network, which produces the guaranteed volume. So health care plans won't pay if you go out of network. The economics would fall apart otherwise -- plans wouldn't be able to negotiate the lower prices because a doctor's office wouldn't see any uptick in volume. Now it depends on the plan, but there are often exceptions for when you're traveling and need emergency care -- they'll pay network rates toward that because it's not a visit that an in-network doctor would have lost. Also, plenty of "gold-plated" plans will cover anything out-of-network as well -- because they're expensive plans they're willing to pay doctors more, and so don't need to provide doctors with volume.
specialp 5y ago
The issue with single payer is all the special interests that already make our costs the highest in the world would lobby to make that single payer pay more. We have this already. Medicare cannot by law negotiate drug prices despite probably being the largest single payer. The out of network provider in an in network hospital is probably the most perverse thing to happen. One could be unconscious at a hospital and have out of network provider Dr Smith LLC stop in for a few minutes and send you her own bill.
throwawayboise 5y ago
The insurance companies own the networks. So it's a way for them to pay themselves rather than pay externally.
shadilay 5y ago
I can't think of any other industry where it's normal to charge different customers different prices for the same good/service.
refurb 5y ago
It typically doesn’t drop to $0? At least all the insurance I’ve had will pay using some formula like “we will cover 80% (instead of 90%) of charges up to the allowed amount (what an in-network would receive”. The issue is that many providers balance bill, so everything above that is billed to the patient and since some negotiated rates are 50% or less of charges, the patient can own more than the insurance. Basically insurance and providers fuck over the patients together.

deregulateMed 5y ago

Just a note, it's possible to lose money accepting some Medicaid insurances. Specifically if you need to hire a translator. $40/hr payout for physical therapy + translator contactor.

bradstewart 5y ago

Totally agreed. My favorite is when you add this scenario to physically being somewhere without any in-network doctors. I cut my hand open climbing in northern New Mexico, bandaids and gauze weren't stopping the bleeding, so I went to the nearest town clinic/urgent care. Ultimately got 8 stitches. My insurance denied (almost) everything. They would later explain that I was supposed to drive myself several hours to Albuquerque to get my hand looked at instead. I say almost because the covered $70 for the lidocaine shot, but literally nothing else. Why they deemed the lidocaine necessary but not the stitches could not be explained. Clearly they had a way to pay the clinic, so wasn't that. Another whacky thing I discovered: the insurance company gets to decide how much, if any, of your uncovered, out-of-pocket bill counts towards your deductible. In this case they deemed $109 of $832 to be the right number, with no explanation as to how they arrived at that sum.

jrs235 5y ago
Should probably have gone to an ER. Emergencies are easier to argue and appeal. "Urgent" (yet less costly) and they assume you still could have waited... it wasn't an emergency yet. I hate our insurance/medical payment/determination system. It's a joke.
- vinceguidry 5y ago
  I went to an in-network urgent care for a particularly painful pinched nerve and got worthless drugs, and the uncovered part of the bill came out more than the covered part. Next time I'll just suffer at home and hope I don't die. It'll amount to the same result.
- Workaccount2 5y ago
  Given the location and possible severity, the only viable way to an emergency room might have been a helicopter. Which insurance almost certainly would not cover. So the insurance is saying "If you paid $80,000 for a medevac, we would have covered your hospital bill".
  - FireBeyond 5y ago
    Hell, a few years ago UHC made the news because they were denying coverage for Flight EMS from serious car accidents due to "lack of pre-authorization".
- ceejayoz 5y ago
  They're looking at clamping down on that, too. https://arstechnica.com/science/2021/06/biggest-health-insurer-plans-to-deny-er-bills-if-it-doubts-you-had-an-emergency/ https://arstechnica.com/science/2021/06/biggest-health-insur... > Doctors and hospitals are condemning plans by UnitedHealthcare—the country’s largest health insurance company—to retroactively deny emergency medical care coverage to members if UHC decides the reason for the emergency medical care wasn’t actually an emergency.
  - sidewndr46 5y ago

jstrom 5y ago

You can theory-craft a non-malicious justification: Insurance trusts Dr. Hibbert will perform the procedure without complications and has negotiated a fixed price of $1K. Insurance doesn't trust Dr. Nick and believes any procedure he performs will result in a second claim later to set things right. Insurance strongly wants you to chose Dr. Hibbert and the only leverage they have is to refuse to pay for Dr. Nick should you go with him. Not sure how plausible that is though--I suppose they could data-mine frequency of follow-up treatment required per doctor--but I've never observed in network/out of network to correspond to a meaningful metric (our local dentist recommended by all the dental specialists around doesn't deal with any insurance companies, while the in-network dentist is pretty clearly padding their work)

inetknght 5y ago
Why doesn't the insurance company trust Dr. Nick? If there's reason to not trust Dr. Nick, then surely the insurance company must disclose it. If there's reason to not trust Dr. Nick, then surely Dr. Nick would have trouble maintaining a medical license. If there's reason to not trust Dr. Nick then surely Dr. Nick's own malpractice insurance would become too onerous for him to keep. No, this smells exactly like what @Someone1234 stated: > Out-of-network was always just a sketchy way for insurance to avoid paying what they should have paid.
- jrs235 5y ago
  Sometimes the trust issue is more about fraudulent claims than one's ability to practice medicine...
  - inetknght 5y ago
    > If there's reason to not trust Dr. Nick, then surely the insurance company must disclose it. That should include "we think Dr. Nick makes fraudulent claims"
  - jakelazaroff 5y ago
    Then why is he still in business? If he's committing insurance fraud, then the insurance company should work with regulators to stop and potentially prosecute him. The onus to prevent fraud should not be on me as a patient.

toast0 5y ago

It kind of depends on the network. For a real owned and operated HMO where every provider in the network buildings and offices is an employee of the network (or under contract as a network provider), in-network only (for non-emergency services) makes a lot of sense to control costs, make staffing predictable, ensure consistency of care, etc. As an insured, you go to one building and get everything taken covered. If you want to go out of network for something, you need a good reason or be willing to pay for the whole thing. When it's a third party HMO network and you've got stuff like a medical office where only some doctors are in network and others aren't, so if your doctor is behind or out sick and you're offered to see another doctor in the interest of time and then you've seen an out of network doctor, that's a totally different deal. Then you've got things like in-office X-ray analyzed by an off-site radiologist whose identity and network status wasn't known before hand. I'd like to see non-emergency medicine take up the same kind of quoting requirements as auto repair. You can't always stop a procedure to update the quote, so provide several quotes for the likely outcomes.

crazygringo 5y ago

I'm not defending it, but there is actually a logical justification here -- it's not just insurance companies being evil. When insurance companies sign up doctors to their network, doctors agree to lower fees (lower profit) but expect to make it up in volume, because the health plan will send them more patients. But that only works if patients are made to stay in-network, which produces the guaranteed volume. So health care plans won't pay if you go out of network. The economics would fall apart otherwise -- plans wouldn't be able to negotiate the lower prices because a doctor's office wouldn't see any uptick in volume. Now it depends on the plan, but there are often exceptions for when you're traveling and need emergency care -- they'll pay network rates toward that because it's not a visit that an in-network doctor would have lost. Also, plenty of "gold-plated" plans will cover anything out-of-network as well -- because they're expensive plans they're willing to pay doctors more, and so don't need to provide doctors with volume.

specialp 5y ago

The issue with single payer is all the special interests that already make our costs the highest in the world would lobby to make that single payer pay more. We have this already. Medicare cannot by law negotiate drug prices despite probably being the largest single payer. The out of network provider in an in network hospital is probably the most perverse thing to happen. One could be unconscious at a hospital and have out of network provider Dr Smith LLC stop in for a few minutes and send you her own bill.

throwawayboise 5y ago

The insurance companies own the networks. So it's a way for them to pay themselves rather than pay externally.

shadilay 5y ago

I can't think of any other industry where it's normal to charge different customers different prices for the same good/service.

refurb 5y ago

It typically doesn’t drop to $0? At least all the insurance I’ve had will pay using some formula like “we will cover 80% (instead of 90%) of charges up to the allowed amount (what an in-network would receive”. The issue is that many providers balance bill, so everything above that is billed to the patient and since some negotiated rates are 50% or less of charges, the patient can own more than the insurance. Basically insurance and providers fuck over the patients together.