|
 Consumers trying to decipher the difference have to ask a lot of
questions to figure out how to manage their bills.
Here are the three key scenarios facing consumers:
* "I do not take your insurance, but I will work with you on the
price."
A growing number of doctors simply are not taking contracts with
insurance companies, although the concentration varies by region and
by specialty. That leaves patients to pay the market rate the doctor
charges, and then submit a receipt to get reimbursement for
out-of-network coverage, if they have it.
In some cases, the pickings can be slim for in-network docs. For
example, 45 percent of psychiatrists do not participate in insurance
networks, according to JAMA Psychiatry.
"The burden of getting the forms right and getting all the paperwork
is placed on the physician," says Dinah Miller, a psychiatrist who
practices in Baltimore and co-authors a blog called Shrink Rap
(http://psychiatrist-blog.blogspot.com/). "If you're seeing eight or
nine patients a day, and several bounce, it's a lot of uncompensated
time."
Primary care physicians are opting out, too. Some are moving to a
concierge model, in which patients pay a subscription fee like $150
a month to see their doctor.
Membership in the Association of American Physicians and Surgeons, a
conservative-libertarian group of private-pay doctors, increases by
about 10 percent a year, says Jane Orient, executive director of the
organization, which has 5,000 members.
Many doctors who say they don't take insurance will make deals with
patients on an individual basis. One key negotiating tip is to know
what your in-network rate would be, typically a discount of about 40
percent, suggests Joe Mondy, a spokesman for insurer Cigna.
You can get this information through your provider's online tools or
by calling the customer service line. But Mondy says to be aware
that the private provider is not bound to accept that price.
* "I will submit the receipt for you, see what I get from the
insurance company and work with you on the difference."
This process is typically referred to as balance billing. It is
largely frowned upon for in-network charges, and even restricted in
some states. But it still goes on in the private-pay world, and
often results in a confusing morass of paperwork.
Even insurance executives find themselves negotiating the fray.
Chris Reidl, director of product for national accounts at insurer
Aetna, paid an up-front fee to one doctor and then submitted the
bill to the insurance company. When the insurance company reimbursed
the doctor for the visit, the office refunded the fee she had paid.
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Consumers need to be on top of this process and pour over their
benefits statements to track the various payments. They also need to
keep after their doctors' offices to get their money back.
* "I will try to negotiate a better rate with your insurance
company."
Some providers have back-channel communications with insurance
companies, trying to get a better reimbursement so their patients
end up paying less out of pocket.
Amy Gordon, a lawyer focusing on benefits issues at McDermott, Will
& Emery in Chicago, facilitates some of these discussions, trying to
get everyone on the same page.
Gordon gives the example of a chiropractor who has a number of
patients on one employer's plan. The going rate for a visit is $200,
and the out-of-network reimbursement offered is $50. The provider
has to choose whether to charge the patients the remainder or
discount it.
"Being out $150 for one person is bad, but being out that much for
10 people is worse," she says. So the provider tries to get more
from the insurance company, and the insurance company tries to get
the provider to join its network. The insurer and the doctor may end
up settling on an $80 reimbursement, and the patients only have to
pay the equivalent of a $20 co-pay.
"A lot of this can be avoided with planning, and finding if there is
an acceptable in-network provider," Gordon says. "If you still want
to go out of network, you can ask the insurance company to give you
an estimate of what they would pay, and then you can at least make a
more informed decision."
(Follow us @ReutersMoney or at http://www.reuters.com/finance/personal-finance.
Editing by Lauren Young and Dan Grebler)
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