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

[Guest guest]

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 PocketbookAn 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 youStaying WellYou 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$85Your Copayment$20Lab tests (done in PCP's office)No cost to youSpecialist visit/fee$150Your Copayment$45If 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