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How Much Is Too Much?

I was skimming the New York Times health and wellness section today and I came across an article about the excessive costs some people have to pay for “out of network” benefits. This really got me thinking about what things really do cost and why some providers feel no guilt with some of their greed. In our practice we do see patients with out of network benefits all the time…and we don’t gouge them because being out of network gives us carte blanche to do it. We have an established fee schedule and we stick to it. It has been established based on fair market value of our services and would not bankrupt someone for receiving some health care services. Why don’t others do this? To make up for lesser payments from in network patients? To pad their pockets? Some places may not even know how much they are charging for things when a patient is out of network and that is the bigger issue.

In healthcare, each company has its own fee schedule that they charge and there is no regulation of this. It’s a free market and you can charge what you would like for whatever services that you are providing. If you have agreed to provider contracts with the various payers (Medicare, Blue Cross, Tufts, etc, etc) then you have agreed to a rate for your services and regardless of what you bill, you are entitled to only that fee and you cannot bill a patient for the remainder. The issue for many providers is that sometimes the rate that you have agreed to isn’t actually enough to cover your costs to deliver the services. No business can survive with that strategy. We are seeing backlash against these contracts by more providers going “out of network” with payers so that they can bill and receive what they feel is a fair reimbursement for their services…which is fair…until you go overboard and cause more problems.
Many patients don’t understand the difference between an in network and out of network provider and the effects it can have on what they owe. Some people are quite simply taken advantage of in emergency situations…you can have your life saved and ruined all at the same time.

We are coming towards a time when pricing will be transparent…and maybe reimbursement should be transparent too. Each insurance company has so many products and rules that it impossible to know them all. Sometime we (in my offices) wont really know what we are getting paid by an insurance company until we actually get our first payment…imagine living in that world…you provide the services but aren’t sure when you will get paid an how much.

Crazy, right??
There is also in injustice as to how various providers get paid differently because of their negotiation power. I know that the major health care powers (Partners Health Care for example) get paid more for their services than my facilities do…and they bill a heck of a lot more too. Are their services better?? No…but they have more leverage to force insurance companies to pay them more. If Partners Health Care tells Blue Cross that they will pull out of the network if they don’t get a rate increase, they get one. If Blue Hills Sports and Spine calls and tells Blue Cross that without a rate increase we are pulling out of the network, we would probably hear some laughter and then a dial tone…just not fair. We recently had a patient that was “out of network” at a local major hospital and they were being billed in excess of $400 for 45 minutes of treatment…ridiculous!!
For patients, make sure when you are choosing a provider you are asking if they are in network and then find out how much they charge…you just might be surprised what you will find out.

Michael Vacon, PT is a managing partner of Blue Hills Sports & Spine Rehabilitation