Doctor Was Out-of-network ...

[scagnt83]

This my friends is one of the biggest problems with our medical system. There is no real disclosure of costs before you do a procedure. Consumers (the ones who pay) have no clue how much anything costs. And to find out how much something will cost, it is often a multi hour process.

When no one knows how much anything costs, then how can anyone know if it is a fair price??

The system is (has been) broken. No other industry in the world fails to disclose how much the cost of a service is... there are laws against that for most industries.

 

[kingbrand]

This my friends is one of the biggest problems with our medical system. There is no real disclosure of costs before you do a procedure. Consumers (the ones who pay) have no clue how much anything costs. And to find out how much something will cost, it is often a multi hour process.

When no one knows how much anything costs, then how can anyone know if it is a fair price??

The system is (has been) broken. No other industry in the world fails to disclose how much the cost of a service is... there are laws against that for most industries.

Possibly I have just been lucky ... up till now they've been pretty good about letting me know in advance whether something is covered by insurance, thus allowing me to choose whether to have it and pay for it myself (as I mentioned in Post #6, I make a point not to request services if I am incapable of paying for them).

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none of them will work unless you call them and try to convince someone to help you.

Alright. Thanks for that heads up, I'll make it a phone call instead.

 

[somarco]

When no one knows how much anything costs, then how can anyone know if it is a fair price??

Most carriers have pricing online for their policyholders. I have used those tools for years with Cigna, UHC, BX, Humana and other carriers.

If you don't know how to use those tools, call the carrier.

Par provider services are priced by carrier. Par providers are prohibited by contract from providing a lower price when an insured receives services.

Consumers are able to find online pricing for most routine items. Brain surgery is another topic entirely, but do you really want the least expensive brain surgeon?

 

[scagnt83]

Most carriers have pricing online for their policyholders. I have used those tools for years with Cigna, UHC, BX, Humana and other carriers.

If you don't know how to use those tools, call the carrier.

Par provider services are priced by carrier. Par providers are prohibited by contract from providing a lower price when an insured receives services.

Consumers are able to find online pricing for most routine items. Brain surgery is another topic entirely, but do you really want the least expensive brain surgeon?

We have had this discussion before.... that does nothing for situations like the OPs when it was not disclosed that a provider was out of network for a major procedure.

It also does nothing because of the way most insurance is structured. For routine procedures the consumer sees no reason to take the time to compare prices.... despite the fact that those underlying prices dictates their Health Insurance Premiums.
For a thousand dollars difference... that ends up being paid by the insurance policy anyways... what reason or incentive do they have to worry about the cost of anything??

THAT is the issue. For most instances of use, there is not a large financial incentive for a consumer to compare prices. So there are no real "checks and balances" at work within the cost of care.

And the insurers have a vested interest in the cost of care increasing... so their "negotiations" with providers are a joke and does not resemble anything close to a free market system.

The pricing of medical care is not based on a free and transparent market.

 

[somarco]

We do agree there is no incentive for policyholder to shop around since insurance pays xs of 80% of the claim. Can't tell you how many time consumer pays their copay and never bothers to read EOB or open bills from providers. Only time they actually read their policy is when the bill collector calls.

insurers have a vested interest in the cost of care increasing.

I don't follow this line of reasoning.

As costs rise so do premiums. Higher premiums means less affordability.

If carriers have no incentive to negotiate lower pricing, why are so many of them going to skinnier networks and PPO's have all but disappeared from the landscape? Almost all IFP plans are now HMO's.

"negotiations" with providers are a joke and does not resemble anything close to a free market system.

Negotiations now, and have been for at least 20 years, a take it or leave it proposition. If the provider does not like the fee schedule they don't sign the MCO agreement.

Same with Medicare and Medicaid.

Take it. Or leave it. No middle ground.

 

[scagnt83]

I don't follow this line of reasoning.

As costs rise so do premiums. Higher premiums means less affordability.

Less affordability on a necessary product does not automatically mean a lower amount of buyers. Obviously there is a balance that must be kept to ensure affordability. But insurance coverage is now at an all time high... it was pretty dang high even before ObamaCare... at least among people that actually had a half decent job.

And higher premiums means higher revenue and higher revenue means higher profits (on a dollar basis).

Even if profit margins shrink because of expansion, they have not shrunk at the rate premiums have climbed imo.

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If carriers have no incentive to negotiate lower pricing, why are so many of them going to skinnier networks and PPO's have all but disappeared from the landscape? Almost all IFP plans are now HMO's.

Well at this point we are talking about artificial intervention via obamacare. Profit margins have been capped via regulation, etc. etc.

But rising premiums were an issue before Obamascare. Over-utilization on low co-pay or hmo plans was an issue before Obamacare.

Sure they have an interest to negotiate to an extent. But pre Obamacare, they had a very real interest in the premiums rising at a nice clip. The irony is that they shot themselves in the foot. Now they have Obamacare and most are now losing money on IFP. Which as you know, is the reason for most of the recent events that you described.

 

[kingbrand]

THAT is the issue. For most instances of use, there is not a large financial incentive for a consumer to compare prices. So there are no real "checks and balances" at work within the cost of care.

And the insurers have a vested interest in the cost of care increasing... so their "negotiations" with providers are a joke and does not resemble anything close to a free market system.

The pricing of medical care is not based on a free and transparent market.

Forgive me if this is stating something that doesn't need stating (and admittedly I haven't read the prior thread that you alluded to) but even if an insurance company has no interest in keeping down the cost of care in general, it clearly has a vested interest in keeping down the cost that it itself is paying out.

 

[somarco]

higher premiums means higher revenue and higher revenue means higher profits (on a dollar basis).

I take it you haven't looked at all the red ink for virtually every carrier on business written since 1/1/14. For almost every one of them, there are no profits.

Of the 30 or so Obamacare co-ops, only 3 are expected to survive .... at least until the end of 2016.

Carriers that have made money on Obamacare are those that were heavily involved in Medicaid before 2014. Molina,Centene, Ambetter and maybe a few more that I have missed made money on Obamacare.

At the same time UHC, Humana, most of the Blue's, Assurant .... the list goes on, lost on Obamacare.

Even if profit margins shrink because of expansion, they have not shrunk at the rate premiums have climbed imo.

There are no profits. Period.

But you are right about premiums expanding.

Why?

All because of the constraints of Obamacare.

Profit margins have been capped via regulation, etc. etc.

In theory, yes.

But the reality is the MLR (which has nothing to do with profit) had nothing to do with losses. The carriers grossly underestimated the level of claims plus the revolving door new entrants who drop coverage a few months after getting their whatever fixed.

rising premiums were an issue before Obamascare.

Tyler, I have been in the health insurance business for over 40 years. Worked in almost every phase of health insurance but I have never seen premiums double in a year the way they have with Obamacare.

But pre Obamacare, they had a very real interest in the premiums rising at a nice clip.

You overlook the fact the insurance industry was highly regulated before Obamacrap. If one carrier was making excessive profits other carriers would come in and disrupt the market.

As an example, in the late 80's there were about dozen stop loss MGU's and profits were really nice. By the mid 90's the number of stop loss MGU's had swollen to over 140. Shortly after the stop loss market imploded and most of those outfits were either gobbled up by a competitor or just ceased to exist.

I know because I was caught up in that mess and almost had to declare bankruptcy over the collapse of one of the MGU's.

 

[scagnt83]

Obviously none of this matters now that Obamacare has stripped all the profits away from the IFP market and they are running in the red. You cant make money from negative profits....

But what got us Obamacare was the out of control rate increases and costs of care that people who didnt have group could no longer afford.

You know good and well I dont support Obamacare... and I am not going to argue one bit that it has caused insane rate increases like never before imagined.
But the carriers brought this on themselves in a lot of ways... so did the american public.

The cost of care will never be contained without consumers being aware of what the actual cost is. That was and still is a major problem with the crazy inflation we have seen in medical care. No checks and balances.

 

[kingbrand]

Obviously none of this matters now that Obamacare has stripped all the profits away from the IFP market and they are running in the red. You cant make money from negative profits....

Amen, brother. I'm still having trouble believing that Obamacare actually passed.