CA Capping OON Charges Under New Law

Sep 1, 2016

  1. dgoldenz
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    dgoldenz Moderator Moderator

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    Curious to see how this works out.

    http://www.modernhealthcare.com/art...ia-surprise-bill-legislation-could-spur-other

     
  2. FLM2
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    FLM2 Guru

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    FLM2, Sep 2, 2016
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  3. scagnt83
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    scagnt83 Worldwide Expert of Everything

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    Im pretty sure that hell just froze over. Kali actually implemented an insurance consumer protection law that is logical and actually protects consumers.

    I think someone put something in the water they are drinking over there...


    This problem is not exclusive to just hospitals these days either. A wholesaler I work with out of Atl had this happen at a normal doctors office. The office was "leasing" some employees from another facility whose doctors were in a different network. A few weeks after his visit he gets a $1k bill for his doctor visit.... despite making sure the "office" was in his network. I told him if it were me I would raise holly hell with that doctors office. But this will only become more common as overhead costs increase. Its cheaper to outsource these days rather than employ directly.
     
  4. somarco
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    somarco GA Medicare Expert

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    Possibly good for the consumer. Restraint of trade for the provider.

    There is a very good reason why providers refuse to sign MCO agreements. They feel there services are worth more than what a carrier pays to other providers.

    Maybe they are justified in wanting to charge more. Maybe not.

    Squeeze a balloon on one end, it gets bigger on the other.

    Obamacare was supposed to control health care costs and premiums.

    Neither was accomplished.

    My feeling is the consumer will lose more than they gain with this type of legislation.

    Noteworthy links below


    Why are such out-of-network bills on the increase? “It’s because insurance companies are creating narrow networks, limiting the number of physicians patients see, so more and more physicians become ‘out of network,’”
    http://www.captodayonline.com/clampdowns-network-billing-climb/


    30 things to know about balance billing
    http://www.beckershospitalreview.com/finance/30-things-to-know-about-balance-billing.html
     
    Last edited: Sep 2, 2016
    somarco, Sep 2, 2016
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  5. scagnt83
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    scagnt83 Worldwide Expert of Everything

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    Perhaps... but the issue is that when a patient asks an office if they are "in network".... there should not be a surprise of $1k in out of network charges at the end.

    My post is not talking about surgeons of specialists... Im talking about family docs and lab techs... and normal doctors visits, not special procedures.


    If it is disclosed that the doctor or lab tech assigned to you is out of network and you CHOOSE to use them then that is fine.

    It is the lack of disclosure that is the issue.


    My mechanic charges more than most. I am happy to use him because he is honest and knows more than most. He is worth the extra money.... but he also gives me an estimate of charges BEFORE doing the work. I CHOOSE to pay a premium. I am not just left in the dark about it.


    Choosing to pay for out-of-network charges is fine. Telling someone their visit will be in-network, but then giving them a doctor that is out-of-network and surprising them with a grand in extra expenses should be against the law.


    In a free market, it doesnt matter what the provider thinks they are worth. It matters what the CUSTOMER thinks they are worth.
     
  6. leevena
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    leevena Guru

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    Need to respectfully disagree with scagnt. Any kind of price controls are not good. While it might provide some kind of temporary relief here, and make people feel good for awhile, there are always unintended consequences. Look back on any of our past experiences, including Nixon wage and price controls.

    The physician office in Atlanta is a new one for me.
     
    leevena, Sep 2, 2016
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  7. somarco
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    somarco GA Medicare Expert

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    We will have to disagree.

    Par/non-par providers have been part of the landscape for 30 years. If policyholders have not bothered to read their policy, they should be penalized.

    The issue of using outside labs has also existed for years. Doctors do not routinely ask patients about who they want as a referral provider or where to send the lab work.

    If the patient expects to use their plan they need to take some responsibility rather than treating their insurance card as an unlimited line of credit.

    If you (the patient) don't ask that is your fault, not the doc.
     
    somarco, Sep 2, 2016
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  8. scagnt83
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    scagnt83 Worldwide Expert of Everything

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    Bob, you obviously did not read my post correctly.

    In my example HE DID ASK.

    - He called the office to ask if they were in his network
    - They said yes
    - They assigned him a doctor that was on lease for a month who was not in his network
    - He got charged $1k for a visit that he was told would cost a $40 co-pay when he called.

    And this has been an issue for consumers for the past 30 years. More so over the past decade. Just because it has existed does not mean it is ok to happen.

    No one is saying that it is an "unlimited line of credit". That is no where near what this or any other example given in this thread is like.

    But when Im paying $1k per month for health insurance.... and I ask a doctors office "will my visit be in-network"... and they say yes... it damn sure better be in-network... all of it.

    Just because something "has been that way" does not mean it is ok to happen or a good thing for the system.

    (but I do enjoy our discussions on price and transparency within the system)
     
    Last edited: Sep 2, 2016
  9. FLM2
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    It's the lack of disclosure that bothers me, particularly with the surgery scenario, which happens all of the time at network facilities.

    Why is it so difficult for a hospital/surgeon/facility, etc to say the following: 'One of the doctors that is part of the surgical team is an out of network provider so your cost for his services will be higher. If you like we can provide alternate doctors that are in network but our preference would be to use the Out of Network doctor for this procedure'.

    Then it is the consumers choice to make and there are no surprises.
     
    FLM2, Sep 2, 2016
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  10. scagnt83
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    scagnt83 Worldwide Expert of Everything

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    I am usually not a fan of price controls. I am a free market kind of guy. But the current healthcare system is not operating in a free market format and hasnt for the past 20 years. A key aspect of a free market is transparency of cost so that consumers can make decisions based on that cost.


    Perhaps a better route to take would be that it is required for them to DISCLOSE to the patient BEFORE BEING BILLED that a certain sub-contractor is not in that office or hospital's network.

    But you would think that would just be common decency... Im sure that you clearly disclose any costs related to your services... why should we not expect the same of our doctors and hospitals? Its not like they dont know what insurance network you are on.
     
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