Interesting timing for this reversal. I doubt fear of vigilante reprisal figured much into their calculations, but they had to have considered the optics of it. Optics seems to be the main...
Interesting timing for this reversal. I doubt fear of vigilante reprisal figured much into their calculations, but they had to have considered the optics of it.
Optics seems to be the main motivator for this announcement, because reading the details, it doesn't seem like ABCBS is reversing course much, if at all. They still intend to deny claims if they don't meet some nebulous criteria, so I'm not sure this is much of a reversal at all. It seems more like they floated firm time criteria that ended up being wholly unpopular, so they simply rescinded the definition and left the policy in place.
Well, crap. Thank you for pointing this out, I was entirely unaware of that nuance. Could you link something that describes the details of this so we can read into it?
It seems more like they floated firm time criteria that ended up being wholly unpopular, so they simply rescinded the definition and left the policy in place.
Well, crap. Thank you for pointing this out, I was entirely unaware of that nuance. Could you link something that describes the details of this so we can read into it?
My apologies, I'm so used to NYT links being paywalled that I've stopped trying to click on them. This one let me read the article. I apologize for my failure of due diligence before taking part...
My apologies, I'm so used to NYT links being paywalled that I've stopped trying to click on them. This one let me read the article.
I apologize for my failure of due diligence before taking part in the conversation.
Relevant portion from the article:
Even now, though, if an anesthesiologist bills for eight hours of services for a procedure that typically lasts four hours, she said, documentation would be required to support the charges: “We won’t automatically approve that.”
The company’s earlier letters to providers stated otherwise, saying that new time limits would be enforced.
The advice said that Anthem Blue Cross Blue Shield for New York, Connecticut and Missouri were changing how they evaluate claims for anesthesia services starting on Feb. 1, 2025.
The standard payment formula is based on medical codes indicating the type of care provided, as well as a time element, anesthesiologists said.
Those in private plans who reported times exceeding the average for a procedure would not be paid at all, Anthem said.
“Claims submitted with reported time above the established number of minutes will be denied,” the company’s letter said.
In a separate missive regarding Medicaid plans, Anthem said that claims for anesthesia services exceeding the set limits would be reimbursed only up to the limit, or preset average time for the procedure.
Looking at this, it seems they are pretending to not understand how 'average' is calculated.
Right? So half the time folks don't get paid? And then next month half of THOSE don't get paid?! This sounds insane to me. I've sat in on a brain surgery one time. The anesthesiologist was there...
Right? So half the time folks don't get paid? And then next month half of THOSE don't get paid?!
Those in private plans who reported times exceeding the average for a procedure would not be paid at all, Anthem said.
“Claims submitted with reported time above the established number of minutes will be denied,” the company’s letter said.
This sounds insane to me.
I've sat in on a brain surgery one time. The anesthesiologist was there before the 6+ hours I sat around, and he was still there when I left. Total surgery time went several HOURS over the six originally expected. I was exhausted from doing nothing for 6 hrs and they (surgeons, anesthesiologist, OR staff) were still standing and (literally) laser focused on the task for 9+ hours. Did that brain surgery go on for longer than average? Maybe? Maybe because it's a big freaking deal and someone might suddenly die? And that they're trying to remove a tumour that's embedded itself into someone's central nervous system and it takes time to carefully remove bits so the person doesn't die or wake up to servere disability?! What are they doing denying claims based on minutes? That garbage wont even pass muster with a car mechanic!
They weren’t floating some random scheme, they were trying to bring reimbursements for anesthesiologist procedures in line with CMS standards, which is to bill by procedure instead of billing by...
They weren’t floating some random scheme, they were trying to bring reimbursements for anesthesiologist procedures in line with CMS standards, which is to bill by procedure instead of billing by hour. The only losers from this would be anesthesiologists.
I suspect the biggest losers would be the people stuck with a full bill because their insurance has denied their claims. Bringing their claims approval policies in line with industry standards...
I suspect the biggest losers would be the people stuck with a full bill because their insurance has denied their claims.
Bringing their claims approval policies in line with industry standards isn't exactly exculpatory if the entire industry is rotten to the core, at least to my mind.
It’s bringing the process in line with what the standards would be in a single payer system. CMS is defining the standard based on how they pay out for Medicare and Medicaid. It’s actually one of...
It’s bringing the process in line with what the standards would be in a single payer system. CMS is defining the standard based on how they pay out for Medicare and Medicaid. It’s actually one of the parts of the system that isn’t rotten.
ABCBS isn't Medicaid/Medicare though. I can't conceive that they'd accept any policy changes if it meant it would diminish their profits. That would fly in the face of every single experience I've...
ABCBS isn't Medicaid/Medicare though. I can't conceive that they'd accept any policy changes if it meant it would diminish their profits. That would fly in the face of every single experience I've ever had even tangentially related to for-profit health insurance companies.
So what's the upside for them for adopting a billing policy in line with a single-payer system? And why should they gain that upside without conceding everything else a single-payer system would cost them?
These companies have made healthcare into a zero-sum game, and then played it dirty. They'd have a helluva uphill struggle to convince me that they should exist at all, let alone that any policy decision they could make would be harmless or even slightly beneficial to policy-holders.
The upside for them is they get to pay anesthesiologists less money. A single payer system is also interested in paying highly compensated specialists less money, because if you let them dictate...
The upside for them is they get to pay anesthesiologists less money. A single payer system is also interested in paying highly compensated specialists less money, because if you let them dictate whatever rate they want they will end up demanding infinite money. This logic doesn’t change just because it’s a for profit payer rather than a state run one.
Cost control is a necessary part of a healthcare system, regardless of how it’s structured.
It also makes the whole thing less administratively complicated, which is why CMS is pressuring payers to adopt more standardized conventions.
That’s how a business works. If there’s competition what policy holders get in return is lower premiums, and less administrative load will mean less paperwork and bills trickling down.
Again: why should they get any benefit without giving something in return to policy-holders?
That’s how a business works. If there’s competition what policy holders get in return is lower premiums, and less administrative load will mean less paperwork and bills trickling down.
Anthem Blue Cross Blue Shield, a major health insurer, on Thursday rolled back a policy change that would have capped payments for anesthesia for patients, and would have denied claims altogether if any given procedure exceeded a time limit.
The policy, which was to be tested before a national rollout, prompted controversy — first from anesthesiologists and then, after a flurry of media reports, from legislators in Connecticut and New York, where the policy was to go into effect in February.
Someone can correct me if I'm wrong, but this struck me as cruel and unusual punishment. I thought the presence of the anesthesiologist was the bulk of the expense, not the injected chemical(s).
Someone can correct me if I'm wrong, but this struck me as cruel and unusual punishment. I thought the presence of the anesthesiologist was the bulk of the expense, not the injected chemical(s).
The corporate entities are large medical practices, the owners of which are usually doctors.
ETA: To be fair, approximately 80% of todays practicing physicians are simply employees of a corporate entity, so it's not exactly "the doctors" that are charging multiples of allowable reimbursement. It's mainly the corporate owners. This question is simplified if the focus is on physician's charges rather than adding the complexity of hospital charges.
The corporate entities are large medical practices, the owners of which are usually doctors.
For balance: from Vox, A big insurer backed off its plan to pay less for anesthesia. That’s bad. Anesthesiologists are incentivized to overbill. Cost overruns would have to be absorbed by the...
Anesthesia services are billed partially on the basis of how long a procedure takes. This creates an incentive for anesthesiologists to err on the side of exaggerating how long their services were required during an operation. And there is evidence that some anesthesiologists may engage in overbilling by overstating the length of a procedure, or the degree of risk a patient faces in undergoing anesthesia.
Cost overruns would have to be absorbed by the anesthesiologist, who can appeal.
“Say there is a contract between an insurance company like Anthem and an anesthesiologist,” Garmon told Vox. “What is always in that contract is a clause that says, ‘You, the provider, agree to accept the reimbursement rules in this contract as payment in full.’ That means the provider cannot then turn around and ask [the patient] for money.”
Insurance companies aren't the #1 reason why healthcare is expensive. Health providers here charge a lot.
But the avarice and inefficiencies of private insurers are not the sole — or even primary — reasons why vital medical services are often unaffordable and inaccessible in the United States. The bigger issue is that America’s health care providers — hospitals, physicians, and drug companies — charge much higher rates than their peers in other wealthy nations.
In 2023, the average physician salary in the United States was $352,000. In Germany, that figure was $160,000; in the United Kingdom, it was $122,000; in France, it was $93,000.
When I lived in the Netherlands, I was surprised to learn that a Dutch GP grosses merely €6k a month. A Dutch anesthesiologist? €11k a month.
American GPs gross 2.5x that. American anesthesiologists? 3.5x that.
It's a dance that requires two players. Insurance means that patients have no realistic ability to price-shop between doctors (for non-emergency care). Insurance denying claims means hospitals...
Insurance companies aren't the #1 reason why healthcare is expensive. Health providers here charge a lot.
It's a dance that requires two players. Insurance means that patients have no realistic ability to price-shop between doctors (for non-emergency care). Insurance denying claims means hospitals overbill so the claims that do get paid make up for those that don't. Further, insurance wants its discount when negotiating rates from the hospital, so the hospital triples the sticker price while maintaining the same income per procedure it always has.
Or sometimes just one. In the area that I live now the insurance companies actually own the hospitals. I had surgery in October and the hospital (owned by my insurance company) billed my insurance...
It's a dance that requires two players.
Or sometimes just one. In the area that I live now the insurance companies actually own the hospitals. I had surgery in October and the hospital (owned by my insurance company) billed my insurance $50,000. The insurance company then paid the hospital (that they own) $1,700 as the "in-network rate" the hospital accepts as a full payment. Something's very clearly broken here.
That $1700 is still distorted by the cost of constant battles with the insurance company to get paid. There are massive numbers of people employed solely for the purpose of filing insurance claims...
That $1700 is still distorted by the cost of constant battles with the insurance company to get paid. There are massive numbers of people employed solely for the purpose of filing insurance claims and appealing denied claims.
I did this job for a while. Hours every single day of nothing but going through denials, finding them in the filing cabinets, printing rebills, addressing, packing, stamping, and re-sending...
I did this job for a while. Hours every single day of nothing but going through denials, finding them in the filing cabinets, printing rebills, addressing, packing, stamping, and re-sending paperwork. All because, as the doctor I was working for said, they virtually always deny just because a significant portion of denials never bother to try again.
It was soul-crushing. The evils of a for-profit medical system cannot be overstated.
What I'm getting at is because the hospital and insurance company are verically-integrated, wouldn't they charge themselves (since its "in-network") the least they could so its not cutting into...
What I'm getting at is because the hospital and insurance company are verically-integrated, wouldn't they charge themselves (since its "in-network") the least they could so its not cutting into the insurance side's numbers? Like just enough to cover all the actual bare combined costs so neither part is taking a hit to their own respective numbers?
I've been trying to understand it, because while $50k is much too high, $1700 also seems too low. My guess is that they have themselves contracted at a loss and make up for it with the contracts...
I've been trying to understand it, because while $50k is much too high, $1700 also seems too low. My guess is that they have themselves contracted at a loss and make up for it with the contracts the hospital has with other insurance providers. So the actual cost of my surgery is paid in part by overcharging someone else's insurance.
I know another health insurance company with hospitals in the area runs the hospital side as non-profit, so I could understand them wanting to keep as much as they can with the insurance side. There might be something similar happening here.
There are laws about how much insurance companies need to spend on payouts (as opposed to things like employee salaries), and owning healthcare providers allows them to have pretty much total...
There are laws about how much insurance companies need to spend on payouts (as opposed to things like employee salaries), and owning healthcare providers allows them to have pretty much total control over how much they pay out, slipping through a loophole in those legal requirements that essentially makes them completely toothless. It's definitely not going to inherently be a better reflection of the free market or anything -- the fact that the same company controls both parties means it's even more insulated from the free market than such payments usually are.
What often happens though, is that the anesthesiologist magically becomes "Out of Network" because they won't sign those contracts and then patients, who have little control over who their...
What often happens though, is that the anesthesiologist magically becomes "Out of Network" because they won't sign those contracts and then patients, who have little control over who their anesthesiologist is for any given surgery (and rarely know whether an ER doctor, radiologist, etc. is going to bill separately from the hospital in advance) are stuck with the costs and appealing for coverage to the insurance company.
It's a fucked up game of "charging X to get reimbursed for Y% of X if insurance, but cash pay price is X-Z but sometimes if you fill out the right paperwork it's 0, but even if they're reimbursed for Y% of X, you have to pay for A% of X as a copay, unless you've hit your OOP and then ...."
I agree with everything you said and the system is the problem - but I want to add just in case anyone needs this info: you don't have to be stuck with a bill because a provider you saw at an...
I agree with everything you said and the system is the problem - but I want to add just in case anyone needs this info: you don't have to be stuck with a bill because a provider you saw at an in-network facility is actually out-of-network. This was already the case for people using Medicare and Medicaid, but the No Surprises Act extended that protection to those with group or individual health plans as well.
It's immensely frustrating that it happens and is set up in a way where both the insurance and providers hope the patient just pays the bill because they don't know better. You have to call your insurance and tell them that the out-of-network provider you saw was out of your control... which is something the insurance would very likely already know, considering they probably have received the billing from an in-network facility showing your surgery, and that date and procedure would line up with the claim they denied from the anesthesiologist for being out-of-network.
Then when your insurance does make a payment to the out-of-network provider, you may get a bill from the provider for whatever insurance didn't cover, which is called balance billing. You have to make another phone call to dispute the bill with the provider this time because the No Surprises Act also prohibits balance billing for services like anesthesia.
I worked customer service for a large insurance company's Medicaid line and about half of my calls were fixing situations like this. (Side note please try to be nice to the people on the phone, we're also victims of the company.)
I don’t think the Vox article is very balanced. The study they cite points out the amount of fraud they are estimating is very small but “no amount of fraud is good.” Thus we should crack down on...
I don’t think the Vox article is very balanced. The study they cite points out the amount of fraud they are estimating is very small but “no amount of fraud is good.” Thus we should crack down on physicians.
In the healthcare space physicians are the only group that has a legal and ethical obligation. Hospitals, insurance companies, and pharmacies are only there to make money off the system often at the expense of patients. I don’t understand why anyone believes Anthem is looking out for the patient and trying to decrease costs. They use third party tools to deny care to patients as a default method to discourage the use of their insurance but physicians are the problem. They raise rates every year to increase their profits but physicians are the reasons health care costs so much. Physician reimbursement has been decreasing for decades and the price of healthcare is increasing because the insurance companies only exist to siphon money out of the system, their role can be replaced by single payer insurance and that would decrease costs like every other country in the world.
The averages in the US are heavily skewed by the owners of large medical practices, which kind of work like a law firm where the partners make bank but the junior associates are doing a lot of the...
The averages in the US are heavily skewed by the owners of large medical practices, which kind of work like a law firm where the partners make bank but the junior associates are doing a lot of the work, seeing only a portion of their billable rate, and aren’t as out of line from other countries. Also American doctors tend to have more rigorous training before they start practicing and our residency programs are insanely selective, so your average doc is probably a decent bit better. (I’d argue it’s probably not necessary to have that level of training and education for much of the care that’s needed but that’s a separate issue).
Of course from the payer/patient perspective that money is still bleeding out of our pocketbooks so it’s irrelevant.
But if we were to have a single payer system or some other kind of socialized healthcare we’d definitely be doing things like this to control costs or physicians and hospital networks would end up absorbing 100% of GDP. Far be it for me to defend health insurance companies, they’re very culpable for the state of things, but we’ve also structured the system such that the payers are responsible for all the decisions that might make people mad. Basically they’re structurally required to be the bad guys. It’s terrible to have profit motive be the North Star around those, sure, but rationing care and cost control is something any healthcare system needs to do and we can’t just blame all of it on “capitalism” or greed. Some of it is just plain scarcity.
My understanding is that other countries held the line on healthcare labor costs and the US didn’t. Going backwards (pay cuts for doctors) doesn’t seem very likely. Kaiser tries to hold down costs...
My understanding is that other countries held the line on healthcare labor costs and the US didn’t. Going backwards (pay cuts for doctors) doesn’t seem very likely. Kaiser tries to hold down costs and as a result, there are strikes. There are also strikes in the UK and South Korea.
I don’t see single-payer fixing it. One thing that might help is to train more doctors, but that’s limited by residency programs.
Residency programs being limited is such a bad reason to not train more doctors. Something has to give in order for us to have more competent doctors, and funding and residency programs being...
Residency programs being limited is such a bad reason to not train more doctors. Something has to give in order for us to have more competent doctors, and funding and residency programs being expanded is a good start.
The idea that what hospitals, physicians, and drug companies charge is completely independent from the avarice and inefficiencies of private insurance in the US is absolutely ridiculous.
But the avarice and inefficiencies of private insurers are not the sole — or even primary — reasons why vital medical services are often unaffordable and inaccessible in the United States. The bigger issue is that America’s health care providers — hospitals, physicians, and drug companies — charge much higher rates than their peers in other wealthy nations.
The idea that what hospitals, physicians, and drug companies charge is completely independent from the avarice and inefficiencies of private insurance in the US is absolutely ridiculous.
Interesting timing for this reversal. I doubt fear of vigilante reprisal figured much into their calculations, but they had to have considered the optics of it.
Optics seems to be the main motivator for this announcement, because reading the details, it doesn't seem like ABCBS is reversing course much, if at all. They still intend to deny claims if they don't meet some nebulous criteria, so I'm not sure this is much of a reversal at all. It seems more like they floated firm time criteria that ended up being wholly unpopular, so they simply rescinded the definition and left the policy in place.
Well, crap. Thank you for pointing this out, I was entirely unaware of that nuance. Could you link something that describes the details of this so we can read into it?
The piece itself quotes a representative that hedges quite a bit on the 'reversal.'
My apologies, I'm so used to NYT links being paywalled that I've stopped trying to click on them. This one let me read the article.
I apologize for my failure of due diligence before taking part in the conversation.
Relevant portion from the article:
Looking at this, it seems they are pretending to not understand how 'average' is calculated.
Right? So half the time folks don't get paid? And then next month half of THOSE don't get paid?!
This sounds insane to me.
I've sat in on a brain surgery one time. The anesthesiologist was there before the 6+ hours I sat around, and he was still there when I left. Total surgery time went several HOURS over the six originally expected. I was exhausted from doing nothing for 6 hrs and they (surgeons, anesthesiologist, OR staff) were still standing and (literally) laser focused on the task for 9+ hours. Did that brain surgery go on for longer than average? Maybe? Maybe because it's a big freaking deal and someone might suddenly die? And that they're trying to remove a tumour that's embedded itself into someone's central nervous system and it takes time to carefully remove bits so the person doesn't die or wake up to servere disability?! What are they doing denying claims based on minutes? That garbage wont even pass muster with a car mechanic!
Yep.
Sounds like the very profitable system working as intended. For the shareholders.
They weren’t floating some random scheme, they were trying to bring reimbursements for anesthesiologist procedures in line with CMS standards, which is to bill by procedure instead of billing by hour. The only losers from this would be anesthesiologists.
I suspect the biggest losers would be the people stuck with a full bill because their insurance has denied their claims.
Bringing their claims approval policies in line with industry standards isn't exactly exculpatory if the entire industry is rotten to the core, at least to my mind.
It’s bringing the process in line with what the standards would be in a single payer system. CMS is defining the standard based on how they pay out for Medicare and Medicaid. It’s actually one of the parts of the system that isn’t rotten.
ABCBS isn't Medicaid/Medicare though. I can't conceive that they'd accept any policy changes if it meant it would diminish their profits. That would fly in the face of every single experience I've ever had even tangentially related to for-profit health insurance companies.
So what's the upside for them for adopting a billing policy in line with a single-payer system? And why should they gain that upside without conceding everything else a single-payer system would cost them?
These companies have made healthcare into a zero-sum game, and then played it dirty. They'd have a helluva uphill struggle to convince me that they should exist at all, let alone that any policy decision they could make would be harmless or even slightly beneficial to policy-holders.
The upside for them is they get to pay anesthesiologists less money. A single payer system is also interested in paying highly compensated specialists less money, because if you let them dictate whatever rate they want they will end up demanding infinite money. This logic doesn’t change just because it’s a for profit payer rather than a state run one.
Cost control is a necessary part of a healthcare system, regardless of how it’s structured.
It also makes the whole thing less administratively complicated, which is why CMS is pressuring payers to adopt more standardized conventions.
Again: why should they get any benefit without giving something in return to policy-holders?
Why does that sound so familiar?
That’s how a business works. If there’s competition what policy holders get in return is lower premiums, and less administrative load will mean less paperwork and bills trickling down.
Someone can correct me if I'm wrong, but this struck me as cruel and unusual punishment. I thought the presence of the anesthesiologist was the bulk of the expense, not the injected chemical(s).
Who is it a punishment for?
The reason they tried this was because of hospital overbilling.
This is a punishment of a patient.
I could be wrong, but looks like reasons of overcharging is a bit complex:
https://money.stackexchange.com/questions/163580/why-do-doctors-seem-to-overcharge-for-services
The corporate entities are large medical practices, the owners of which are usually doctors.
This is already standard practice for Medicare in the US. They were shifting policies to be closer to the billing standard set by the government.
For balance: from Vox, A big insurer backed off its plan to pay less for anesthesia. That’s bad.
Anesthesiologists are incentivized to overbill.
Cost overruns would have to be absorbed by the anesthesiologist, who can appeal.
Insurance companies aren't the #1 reason why healthcare is expensive. Health providers here charge a lot.
When I lived in the Netherlands, I was surprised to learn that a Dutch GP grosses merely €6k a month. A Dutch anesthesiologist? €11k a month.
American GPs gross 2.5x that. American anesthesiologists? 3.5x that.
It's a dance that requires two players. Insurance means that patients have no realistic ability to price-shop between doctors (for non-emergency care). Insurance denying claims means hospitals overbill so the claims that do get paid make up for those that don't. Further, insurance wants its discount when negotiating rates from the hospital, so the hospital triples the sticker price while maintaining the same income per procedure it always has.
Or sometimes just one. In the area that I live now the insurance companies actually own the hospitals. I had surgery in October and the hospital (owned by my insurance company) billed my insurance $50,000. The insurance company then paid the hospital (that they own) $1,700 as the "in-network rate" the hospital accepts as a full payment. Something's very clearly broken here.
So would $1700 more likely be the free-market undistorted actual cost/price of this medical visit?
That $1700 is still distorted by the cost of constant battles with the insurance company to get paid. There are massive numbers of people employed solely for the purpose of filing insurance claims and appealing denied claims.
I did this job for a while. Hours every single day of nothing but going through denials, finding them in the filing cabinets, printing rebills, addressing, packing, stamping, and re-sending paperwork. All because, as the doctor I was working for said, they virtually always deny just because a significant portion of denials never bother to try again.
It was soul-crushing. The evils of a for-profit medical system cannot be overstated.
What I'm getting at is because the hospital and insurance company are verically-integrated, wouldn't they charge themselves (since its "in-network") the least they could so its not cutting into the insurance side's numbers? Like just enough to cover all the actual bare combined costs so neither part is taking a hit to their own respective numbers?
I've been trying to understand it, because while $50k is much too high, $1700 also seems too low. My guess is that they have themselves contracted at a loss and make up for it with the contracts the hospital has with other insurance providers. So the actual cost of my surgery is paid in part by overcharging someone else's insurance.
I know another health insurance company with hospitals in the area runs the hospital side as non-profit, so I could understand them wanting to keep as much as they can with the insurance side. There might be something similar happening here.
There are laws about how much insurance companies need to spend on payouts (as opposed to things like employee salaries), and owning healthcare providers allows them to have pretty much total control over how much they pay out, slipping through a loophole in those legal requirements that essentially makes them completely toothless. It's definitely not going to inherently be a better reflection of the free market or anything -- the fact that the same company controls both parties means it's even more insulated from the free market than such payments usually are.
What often happens though, is that the anesthesiologist magically becomes "Out of Network" because they won't sign those contracts and then patients, who have little control over who their anesthesiologist is for any given surgery (and rarely know whether an ER doctor, radiologist, etc. is going to bill separately from the hospital in advance) are stuck with the costs and appealing for coverage to the insurance company.
It's a fucked up game of "charging X to get reimbursed for Y% of X if insurance, but cash pay price is X-Z but sometimes if you fill out the right paperwork it's 0, but even if they're reimbursed for Y% of X, you have to pay for A% of X as a copay, unless you've hit your OOP and then ...."
The whole system is the problem.
I agree with everything you said and the system is the problem - but I want to add just in case anyone needs this info: you don't have to be stuck with a bill because a provider you saw at an in-network facility is actually out-of-network. This was already the case for people using Medicare and Medicaid, but the No Surprises Act extended that protection to those with group or individual health plans as well.
It's immensely frustrating that it happens and is set up in a way where both the insurance and providers hope the patient just pays the bill because they don't know better. You have to call your insurance and tell them that the out-of-network provider you saw was out of your control... which is something the insurance would very likely already know, considering they probably have received the billing from an in-network facility showing your surgery, and that date and procedure would line up with the claim they denied from the anesthesiologist for being out-of-network.
Then when your insurance does make a payment to the out-of-network provider, you may get a bill from the provider for whatever insurance didn't cover, which is called balance billing. You have to make another phone call to dispute the bill with the provider this time because the No Surprises Act also prohibits balance billing for services like anesthesia.
I worked customer service for a large insurance company's Medicaid line and about half of my calls were fixing situations like this. (Side note please try to be nice to the people on the phone, we're also victims of the company.)
Appreciate this, my partner is Medicare/Medicaid and they mostly write off his bills because his income is untouchable.
But yeah this is good info
I don’t think the Vox article is very balanced. The study they cite points out the amount of fraud they are estimating is very small but “no amount of fraud is good.” Thus we should crack down on physicians.
In the healthcare space physicians are the only group that has a legal and ethical obligation. Hospitals, insurance companies, and pharmacies are only there to make money off the system often at the expense of patients. I don’t understand why anyone believes Anthem is looking out for the patient and trying to decrease costs. They use third party tools to deny care to patients as a default method to discourage the use of their insurance but physicians are the problem. They raise rates every year to increase their profits but physicians are the reasons health care costs so much. Physician reimbursement has been decreasing for decades and the price of healthcare is increasing because the insurance companies only exist to siphon money out of the system, their role can be replaced by single payer insurance and that would decrease costs like every other country in the world.
The averages in the US are heavily skewed by the owners of large medical practices, which kind of work like a law firm where the partners make bank but the junior associates are doing a lot of the work, seeing only a portion of their billable rate, and aren’t as out of line from other countries. Also American doctors tend to have more rigorous training before they start practicing and our residency programs are insanely selective, so your average doc is probably a decent bit better. (I’d argue it’s probably not necessary to have that level of training and education for much of the care that’s needed but that’s a separate issue).
Of course from the payer/patient perspective that money is still bleeding out of our pocketbooks so it’s irrelevant.
But if we were to have a single payer system or some other kind of socialized healthcare we’d definitely be doing things like this to control costs or physicians and hospital networks would end up absorbing 100% of GDP. Far be it for me to defend health insurance companies, they’re very culpable for the state of things, but we’ve also structured the system such that the payers are responsible for all the decisions that might make people mad. Basically they’re structurally required to be the bad guys. It’s terrible to have profit motive be the North Star around those, sure, but rationing care and cost control is something any healthcare system needs to do and we can’t just blame all of it on “capitalism” or greed. Some of it is just plain scarcity.
My understanding is that other countries held the line on healthcare labor costs and the US didn’t. Going backwards (pay cuts for doctors) doesn’t seem very likely. Kaiser tries to hold down costs and as a result, there are strikes. There are also strikes in the UK and South Korea.
I don’t see single-payer fixing it. One thing that might help is to train more doctors, but that’s limited by residency programs.
Residency programs being limited is such a bad reason to not train more doctors. Something has to give in order for us to have more competent doctors, and funding and residency programs being expanded is a good start.
The idea that what hospitals, physicians, and drug companies charge is completely independent from the avarice and inefficiencies of private insurance in the US is absolutely ridiculous.
Mirror: https://archive.is/v0ERV