http://www.ahip.org/content/pressrelease.aspx?docid=22301 is the place to find the press release from AHIP (health insurance organization) where the reaction to attorney general Cuomo's lawsuit regarding usual and customary charges and unreasonably low reimbursement rates for out of network providers is "welcomed" by insurance companies.
Touting their success at cost containment and quality improvement, which is usually terminology used for premium increase/coverage cutting and subcontracting out "services" that try to manage wellness respectively, the insurance industry has finally pointed the finger at another culprit: the doctors. The response asks why someone is being charged $200 for an office visit in the first place instead of explaining why reimbursement rates are so low.
This is a good thing. The insureds have been squeezed enough. Now, in a continued effort to protect their golden goose, doctors will have to answer for their greed. Why? Because this is a combination greed problem.
Task a day insurance: Doctors don't care who pays them but they require payment. Doctors are not required to accept anyone's insurance...
Why do people end up in the out of network provider situation? Because there is not a participating provider that they can or are willing to use.
Participating providers exchange participation with an insurer for the BENEFIT of a larger base of people they will treat who seek an in network provider. Now for the greed factor. Insurers want to pay less and charge more so their network of providers reflects the fact that they want to pay less for physician participation in their insurance plan.
A provider charging $200 will receive less from an insurance company (a lesser rate that is part of their contract). But, fewer doctors want to accept the lesser rate so, instead they are not participating providers. Outside the network they can charge whatever the market will bear.
You need a doctor and can't find a participating provider, you go outside network. You are charged $200 an hour and receive reimbursement for a significantly lesser amount. Either the doctor doesn't get paid in full or you pay out of pocket to cover the expense.
The lawsuit alleges that insurance companies aren't paying ENOUGH of the amount charged.
The AHIP response alleges that the doctors are charging too much.
Why should anyone care how much it costs the consumer? Typically nobody does. That's why we see new plans describing higher deductibles, private fee for service and the like, because under those plans, insureds pay the ever-widening gap between the cost of service and the cost covered by insurance. That's why the attorney general's actions are good. While not addressing the soaring cost of the services (health care), it will bring to light the ever-increasing reduction in coverage for those costs. And the insurers, well their response is to point their fingers at the doctors.
Goal: Mandatory participation in at least some health plans would be progress. Physicians should be required to participate in a certain number of health plans but they are not. As they follow their own money and assume that the free market will continue to support their double digit pay raises, people should not listen to the talking heads of conservatism and their free market I've got my millions and can pay for health care approach, this is anti consumer.
Insurers arguing for price controls on physician fees are arguing for themselves, why should they have to reimburse at rates that reflect these outrageous charges? After all, that's why they're cutting coverage, it costs too much. But consumers need to remember that if health insurance does not pay for medical care--not preventive care, medical care, then we need another means of paying for that care, for doctors, yes, they accept cash.
**Read the 1/17/08 about PFFS Private Fee For Service health plans being marketed and make sure you understand that these plans are not good for the insured.
