Re: Inny vs Outy Network Costs for Patients - effect on insured patient seeing out-of-network Physician

[Guest guest]

,

Here are my random thoughts, but yes,

going OON is definitely a financial disincentive:

We personally have a high-deductible plan

that requires use of an in-network physician except in an emergency or out of

the area. Unless one of us ends up in the hospital or ER one year, it’s

highly unlikely that we will ever hit our deductible of $3500 per patient.

If I go to a participating provider who bills me $100 and the contracted rate

is $60, I pay $60 and it is applied towards my deductible. If I go to a

non-par provider who bills me $100, but offers a same-day discount of 20%

($80), then I pay $80. However, $0 is applied to my deductible because we

went OON - our deductible only applies to in-network providers, except in an

emergency situation. Likewise if I have a test done that is a non-covered

service…$0 applies to my deductible and I pay the amount in full. Our

co-pays don’t kick in until after our deductibles have been met.

Because we likely will never hit our deductible, it doesn’t make much

difference to me if I go in- or out-of-network unless I’m going to end up

going to the doctor more than once/year.

There are, of course, many different plans

out there. Around here, we’re seeing fewer and fewer patients with

a straight co-pay unless they have an HMO. We are seeing more and more

co-insurance, whereby the patient is responsible for a % of the contracted

rate. If they go OON, the % is higher (typically 20% vs 40%), and the %

is still of what their “Usual & Customary” rate is. So in

the example above, if the patient goes in network, and the contracted rate is $60,

the patient pays 20%, or $12. If the patient goes out of network, they

pay 40% of the $60 + the difference between the contracted rate and the rate

that the OON provider charged. In the above example, where the OON

offered a 20% discount for paying cash, the patient would pay $24 coinsurance

plus $20 (the difference between the amount paid - $80 – and the

insurance company’s U & C rate of $60), for a total of $44.

Pratt

Office Manager

Oak Tree Internal Medicine P.C

www.prattmd.info

From: [mailto: ] On Behalf Of Locke

Sent: Saturday, November 27, 2010

1:47 PM

To: ;

'Practice Management Issues'

Subject:

Inny vs Outy Network Costs for Patients - effect on insured patient seeing

out-of-network Physician

Could someone that understands this area please explain how not

being on an insurance's panel impacts patients when they see me as a

non-participating provider for their insurance?

Was the cost to the patient a wash in the overall scheme -- or

does it cost them more to see me?

If patients have a $5,000 deductible that they aren't likely to

meet each year - why wouldn't they just pay me a reasonable fee for service as

out of network doc.

The only quirk I've seen is that many insurances have 2

deductibles...one for In-Network and one for Out-of-Network - and they act

differently.

Plus, some insurances - Medicaid in some states - don't allow you

to bill the patient - REGARDLESS of whether you are participating in the state

Medicaid program -- This is how Colorado

works - even if the patient wants to pay me directly, I can't accept payment or

bill the patient if I see that Medicaid patient.

Also, even if your state allows you to contract directly with a

Medicaid patient - some states won't allow a non-participating physician to

write an order for the patient -- ie referral, medical equipment, etc -- at

least I think this is true.

But the differences between in/out network appears significant

enough to really prevent most patients who use their insurance regularly from

going to a provider OON.

See... http://www.zapbrochure.com/indiv/ncssPrimary.pdf

This difference on this plan is fairly stark - IMHO.

Here is an example for this company's plan... http://www.trincoll.edu/NR/rdonlyres/6CC1DB25-532C-41DA-BF63-FEA0F3539ADA/0/ComparisonofBenefits2010.pdf

I'll send this as a 2nd e-mail.

From what I gather from Dr. Google - in/out network...

http://help.changehealthcare.com/system/pdfs/13/original/in_and_out_of_network_-_blue.pdf?1253809465

How To: Understand In-Network

vs. Out-of-Network

Understanding How In-Network vs.

Out-of-Network May Affect Your Pocketbook

An example: A visit to an in-network physician may charge $100

for an office visit. Your insurance company has contracted with them to

discount this visit to $60.

If your insurance company covers 80% of the cost, the patient

responsibility would be $12.

Compare with an out-of-network physician that also charges $100 for the visit.

Without the negotiated rate from your insurance company, your cost will remain

$100. For out-of-network providers and care,

your insurance may only cover 50%, making your patient responsibility $50.

======================

In the example

above, I suppose another scenario would be...the patient doesn't get charged

the $100, but gets a cash discount of 20% off - so the fee is $80.

So, in the OON

example above -- $80 charged -- Insurance pays 50% or $40 - patient responsible

for $40.

But typically,

isn't there a $20, $30, $40 copay for many visits -- so if the patient is

paying $20 on the visit anyway, doesn't that affect everything, too?

========================

Cigna does this

for PPO type patients...

http://www.cigna.com/our_plans/medical/ppo/for_you.html

How a

PPO might work for you

Staying Well

You

choose a CIGNA physician and set up an appointment for a wellness exam. Your

physician orders some lab tests and suggests you see a specialist about some

problems you have with your stomach. You make an appointment with a specialist

in the CIGNA PPO network

Cost Example

PCP office

visit/exam fee

$85

Your Copayment

$20

Lab tests (done

in PCP's office)

No cost to you

Specialist

visit/fee

$150

Your Copayment

$45

If you choose to see a physician who is not

in the PPO network, you will have to pay the full amount until you meet your

deductible, then pay a predetermined coinsurance amount.

It appears that

going Out of Network for an insurance provides a steep financial disincentive

for a patient to continue seeing a doctor as an Out of Network provider.

Thoughts?

Locke, MD

[Guest guest]

Thanks, ,

That's just wacky.

No wonder nobody can figure out what the heck is going on with their insurance.

Thanks for the feedback.

Locke, MD

 

,

Here are my random thoughts, but yes, going OON is definitely a financial disincentive:

 

We personally have a high-deductible plan that requires use of an in-network physician except in an emergency or out of the area.  Unless one of us ends up in the hospital or ER one year, it’s highly unlikely that we will ever hit our deductible of $3500 per patient.  If I go to a participating provider who bills me $100 and the contracted rate is $60, I pay $60 and it is applied towards my deductible.  If I go to a non-par provider who bills me $100, but offers a same-day discount of 20% ($80), then I pay $80.  However, $0 is applied to my deductible because we went OON - our deductible only applies to in-network providers, except in an emergency situation.  Likewise if I have a test done that is a non-covered service…$0 applies to my deductible and I pay the amount in full.  Our co-pays don’t kick in until after our deductibles have been met.  Because we likely will never hit our deductible, it doesn’t make much difference to me if I go in- or out-of-network unless I’m going to end up going to the doctor more than once/year.

 

There are, of course, many different plans out there.  Around here, we’re seeing fewer and fewer patients with a straight co-pay unless they have an HMO.  We are seeing more and more co-insurance, whereby the patient is responsible for a % of the contracted rate.  If they go OON, the % is higher (typically 20% vs 40%), and the % is still of what their “Usual & Customary” rate is.  So in the example above, if the patient goes in network, and the contracted rate is $60, the patient pays 20%, or $12.  If the patient goes out of network, they pay 40% of the $60 + the difference between the contracted rate and the rate that the OON provider charged.  In the above example, where the OON offered a 20% discount for paying cash, the patient would pay $24 coinsurance plus $20 (the difference between the amount paid - $80 – and the insurance company’s U & C rate of $60), for a total of $44.

 

Pratt

Office Manager

Oak Tree Internal Medicine P.C

www.prattmd.info

From: [mailto: ] On Behalf Of Locke

Sent: Saturday, November 27, 2010 1:47 PMTo: ; 'Practice Management Issues'

Subject: Inny vs Outy Network Costs for Patients - effect on insured patient seeing out-of-network Physician

 

 

Could someone that understands this area please explain how not being on an insurance's panel impacts patients when they see me as a non-participating provider for their insurance?

 

Was the cost to the patient a wash in the overall scheme -- or does it cost them more to see me?

 

If patients have a $5,000 deductible that they aren't likely to meet each year - why wouldn't they just pay me a reasonable fee for service as out of network doc.

 

The only quirk I've seen is that many insurances have 2 deductibles...one for In-Network and one for Out-of-Network - and they act differently.

Plus, some insurances - Medicaid in some states - don't allow you to bill the patient - REGARDLESS of whether you are participating in the state Medicaid program -- This is how Colorado works - even if the patient wants to pay me directly, I can't accept payment or bill the patient if I see that Medicaid patient.

Also, even if your state allows you to contract directly with a Medicaid patient - some states won't allow a non-participating physician to write an order for the patient -- ie referral, medical equipment, etc -- at least I think this is true. 

 

But the differences between in/out network appears significant enough to really prevent most patients who use their insurance regularly from going to a provider OON.

 

See... http://www.zapbrochure.com/indiv/ncssPrimary.pdf

 

This difference on this plan is fairly stark - IMHO.

 

Here is an example for this company's plan... http://www.trincoll.edu/NR/rdonlyres/6CC1DB25-532C-41DA-BF63-FEA0F3539ADA/0/ComparisonofBenefits2010.pdf

 

I'll send this as a 2nd e-mail.

 

From what I gather from Dr. Google - in/out network...

 

http://help.changehealthcare.com/system/pdfs/13/original/in_and_out_of_network_-_blue.pdf?1253809465

 

How To: Understand In-Network vs. Out-of-Network

Understanding How In-Network vs. Out-of-Network May Affect Your Pocketbook

An example: A visit to an in-network physician may charge $100 for an office visit. Your insurance company has contracted with them to discount this visit to $60.

If your insurance company covers 80% of the cost, the patient responsibility would be $12. Compare with an out-of-network physician that also charges $100 for the visit. Without the negotiated rate from your insurance company, your cost will remain $100. For out-of-network providers and care,

your insurance may only cover 50%, making your patient responsibility $50.

 

 

======================

In the example above, I suppose another scenario would be...the patient doesn't get charged the $100, but gets a cash discount of 20% off - so the fee is $80.

So, in the OON example above -- $80 charged -- Insurance pays 50% or $40 - patient responsible for $40.

But typically, isn't there a $20, $30, $40 copay for many visits -- so if the patient is paying $20 on the visit anyway, doesn't that affect everything, too?

========================

Cigna does this for PPO type patients...

 

http://www.cigna.com/our_plans/medical/ppo/for_you.html

 

How a PPO might work for you

Staying Well

You choose a CIGNA physician and set up an appointment for a wellness exam. Your physician orders some lab tests and suggests you see a specialist about some problems you have with your stomach. You make an appointment with a specialist in the CIGNA PPO network

 

Cost Example

 

PCP office visit/exam fee

$85

 

Your Copayment

$20

 

Lab tests (done in PCP's office)

No cost to you

 

Specialist visit/fee

$150

 

Your Copayment

$45

 

If you choose to see a physician who is not in the PPO network, you will have to pay the full amount until you meet your deductible, then pay a predetermined coinsurance amount.

It appears that going Out of Network for an insurance provides a steep financial disincentive for a patient to continue seeing a doctor as an Out of Network provider.

 

Thoughts?

 

Locke, MD

[Guest guest]

It smells like insurance companies trying to control us and not about choice, not about freedom to choose

 

,

Here are my random thoughts, but yes, going OON is definitely a financial disincentive:

 

We personally have a high-deductible plan that requires use of an in-network physician except in an emergency or out of the area.  Unless one of us ends up in the hospital or ER one year, it’s highly unlikely that we will ever hit our deductible of $3500 per patient.  If I go to a participating provider who bills me $100 and the contracted rate is $60, I pay $60 and it is applied towards my deductible.  If I go to a non-par provider who bills me $100, but offers a same-day discount of 20% ($80), then I pay $80.  However, $0 is applied to my deductible because we went OON - our deductible only applies to in-network providers, except in an emergency situation.  Likewise if I have a test done that is a non-covered service…$0 applies to my deductible and I pay the amount in full.  Our co-pays don’t kick in until after our deductibles have been met.  Because we likely will never hit our deductible, it doesn’t make much difference to me if I go in- or out-of-network unless I’m going to end up going to the doctor more than once/year.

 

There are, of course, many different plans out there.  Around here, we’re seeing fewer and fewer patients with a straight co-pay unless they have an HMO.  We are seeing more and more co-insurance, whereby the patient is responsible for a % of the contracted rate.  If they go OON, the % is higher (typically 20% vs 40%), and the % is still of what their “Usual & Customary” rate is.  So in the example above, if the patient goes in network, and the contracted rate is $60, the patient pays 20%, or $12.  If the patient goes out of network, they pay 40% of the $60 + the difference between the contracted rate and the rate that the OON provider charged.  In the above example, where the OON offered a 20% discount for paying cash, the patient would pay $24 coinsurance plus $20 (the difference between the amount paid - $80 – and the insurance company’s U & C rate of $60), for a total of $44.

 

Pratt

Office Manager

Oak Tree Internal Medicine P.C

www.prattmd.info

From: [mailto: ] On Behalf Of Locke

Sent: Saturday, November 27, 2010 1:47 PMTo: ; 'Practice Management Issues'

Subject: Inny vs Outy Network Costs for Patients - effect on insured patient seeing out-of-network Physician

 

 

Could someone that understands this area please explain how not being on an insurance's panel impacts patients when they see me as a non-participating provider for their insurance?

 

Was the cost to the patient a wash in the overall scheme -- or does it cost them more to see me?

 

If patients have a $5,000 deductible that they aren't likely to meet each year - why wouldn't they just pay me a reasonable fee for service as out of network doc.

 

The only quirk I've seen is that many insurances have 2 deductibles...one for In-Network and one for Out-of-Network - and they act differently.

Plus, some insurances - Medicaid in some states - don't allow you to bill the patient - REGARDLESS of whether you are participating in the state Medicaid program -- This is how Colorado works - even if the patient wants to pay me directly, I can't accept payment or bill the patient if I see that Medicaid patient.

Also, even if your state allows you to contract directly with a Medicaid patient - some states won't allow a non-participating physician to write an order for the patient -- ie referral, medical equipment, etc -- at least I think this is true. 

 

But the differences between in/out network appears significant enough to really prevent most patients who use their insurance regularly from going to a provider OON.

 

See... http://www.zapbrochure.com/indiv/ncssPrimary.pdf

 

This difference on this plan is fairly stark - IMHO.

 

Here is an example for this company's plan... http://www.trincoll.edu/NR/rdonlyres/6CC1DB25-532C-41DA-BF63-FEA0F3539ADA/0/ComparisonofBenefits2010.pdf

 

I'll send this as a 2nd e-mail.

 

From what I gather from Dr. Google - in/out network...

 

http://help.changehealthcare.com/system/pdfs/13/original/in_and_out_of_network_-_blue.pdf?1253809465

 

How To: Understand In-Network vs. Out-of-Network

Understanding How In-Network vs. Out-of-Network May Affect Your Pocketbook

An example: A visit to an in-network physician may charge $100 for an office visit. Your insurance company has contracted with them to discount this visit to $60.

If your insurance company covers 80% of the cost, the patient responsibility would be $12. Compare with an out-of-network physician that also charges $100 for the visit. Without the negotiated rate from your insurance company, your cost will remain $100. For out-of-network providers and care,

your insurance may only cover 50%, making your patient responsibility $50.

 

 

======================

In the example above, I suppose another scenario would be...the patient doesn't get charged the $100, but gets a cash discount of 20% off - so the fee is $80.

So, in the OON example above -- $80 charged -- Insurance pays 50% or $40 - patient responsible for $40.

But typically, isn't there a $20, $30, $40 copay for many visits -- so if the patient is paying $20 on the visit anyway, doesn't that affect everything, too?

========================

Cigna does this for PPO type patients...

 

http://www.cigna.com/our_plans/medical/ppo/for_you.html

 

How a PPO might work for you

Staying Well

You choose a CIGNA physician and set up an appointment for a wellness exam. Your physician orders some lab tests and suggests you see a specialist about some problems you have with your stomach. You make an appointment with a specialist in the CIGNA PPO network

 

Cost Example

 

PCP office visit/exam fee

$85

 

Your Copayment

$20

 

Lab tests (done in PCP's office)

No cost to you

 

Specialist visit/fee

$150

 

Your Copayment

$45

 

If you choose to see a physician who is not in the PPO network, you will have to pay the full amount until you meet your deductible, then pay a predetermined coinsurance amount.

It appears that going Out of Network for an insurance provides a steep financial disincentive for a patient to continue seeing a doctor as an Out of Network provider.

 

Thoughts?

 

Locke, MD

-- M.D.www.elainemd.comOffice: Go in the directions of your dreams and live the life you've imagined.

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