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It is not well-known that some large insurance companies have a specific tactic that they employ against out-of-network medical groups even for pre-approved or
by OrvalWintermute 5y ago
It is not well-known that some large insurance companies have a specific tactic that they employ against out-of-network medical groups even for pre-approved or emergency work (Some practices that are out-of-network will charge exponential multiples for services which is another grievious issue).
The large insurer will send checks for goods & services directly to the patient, rather than to the practice(s) that performed the service, even if this is a fairly reasonable cost.
Patients see a check for $8,000 and $25,000 that is supposed to go to the trauma surgeon's practice that initially stabilized the patient, followed by the Plastic Surgeon's practice that spent 16 hours, 2 titanium plates, and a large number of titanium screws, and biologic implants reconstructing the patient's face. And, similar for the small consults $300 consults to Opthamology and Neurology that are common to severe head trauma involving optic nerves, relatively minor brain injures and significant facial trauma.
Instead of providing it to the practice to pay for the plates/screws, and delivered services, the patient spends the money. Then the patient gets sued.
This is not uncommon unfortunately - even for medical practices that TRY to be in-network with every single insurer, AND medicare/medicaid.
- wolpoli 5y agoI reread this twice, but I am still not sure how this helps the insurance company through. Is there something I missed? Or is this intend to cause administrative issues for out-of-network medical groups?
- OrvalWintermute 5y agoIt puts the insurance company in the driver's seat when it comes to negotiations, and it severely hampers the administrative side of medical practice performing the services, because they are in the awkward position of having to sue a patient, or put liens/garnishments against a patient's income/house. Insurance companies may not be at all helpful in this process either.
- edmundsauto 5y agoi used the work in the substance abuse treatment space, where it's even more impactful. People with addictions go to treatment for 30-45 days, and when they get home, they have a $30k check to pay for the treatment. Same deal - insurance pays the individual who pays the center. But I could not imagine a worse recipient, in terms of responsibility, than a recently recovered addict.
- lotsofpulp 5y agoWhy would a substance abuse treatment provider agree to treat a customer if their insurance company will not pay the provider directly?
- edmundsauto 5y agoBecause they generally get their money, and because that's kinda how insurance works. It also may not have been obvious which situation would arise when they did the admission. Additionally, many places charge $5-10k directly and then bill insurance to the max they can - even if they can't always collect the check sent to the patient, it's still profitable. (IIRC, cost to admit a patient was $7-11k/month at the facilities we saw.)
- lotsofpulp 5y agoIt still does not make any sense to me that a business would continue engaging with another business that is causing them to lose money. If a business is getting ripped off, then they need to ask for cash up front, or have contracts requiring direct payment. But if they are going to continue willingly engaging with a party that jerks them around, I do not see who they have to blame but themselves.
- edmundsauto 5y agoTo be clear, I'm not suggesting the facilities are getting ripped off. In reddit terms, Everyone Sucks Here. Facilities use every shady tactic to get people in the door, so nobody should shed a tear for them. My overall answer is that companies that bill insurance live in a complex world. Insurance tries to dodge payouts and will pay the insured; the facilities try to jam billing. Perhaps an anecdote will be representative: I worked for one of the biggest providers, with dozens of facilities. They had a call center whose job it was to get insurance to approve another 3 days of treatment (30 day stay = 10 of these calls). Insurance companies don't staff their end, so the call centers were paying people to wait on the line for several hours, just to get treatment approved. (I ended up building a Twilio integration to queue up without a person on the phone.) This is just a shitty, awful area of medicine and business and insurance.