There are various reasons why a doctor will deny a person's health coverage. Reuters' Beth Pinsker breaks down the three most-common ways in which they do so.
1."I do not take your insurance, but I will work with you on the price."
According to Pinsker, a growing number of physicians are not accepting contracts with insurance companies, leaving patients to pay for services, and then submit a receipt to receive reimbursement for out-of-network care. According to JAMA Psychiatry, about 45% of psychiatrists no longer participate in an insurance network.
In addition, some doctors are moving to a concierge model, in which patients pay a monthly subscription fee to see their physicians.
Generally, physicians who do not take insurance will make deals with individual patients. Experts say knowing in-network rates can help patients with negotiations.
2. I will submit the receipt for you, see what I get from the insurance company and work with you on the difference."
In a process often referred to as "balance billing," physicians will submit the patient's claim to the insurance company and ask patients to help pay the difference between what the insurer pays for out-of-network care and what the doctor charges.
According to Pinsker, this process is "largely frowned upon" for in-network payments and is actually restricted in some states.
3. "I will try to negotiate a better rate with your insurance company."
Some physicians have "back-channel" communications with insurers in which they attempt to get better out-of-network reimbursements so their patients can pay less out of pocket.
Amy Gordon, a benefits issues lawyer at McDermott, Will & Emery, offers an example of a chiropractor that has a lot of patients on one employer's plan. The going rate for a visit is $200, but the out-of-network payment is only $50, meaning the provider must decide whether he or she will charge the patients the remainder or discount the service.
Gordon says, "Being out $150 for one person is bad, but being out that much for 10 people is worse," which is why the provider tries to get a larger reimbursement from the insurer, while the insurer attempts to persuade the physician to join its network. Often, the two entities will compromise on a higher reimbursement rate (Pinsker, Reuters/TIME, 8/20).
What's your primary care IQ?
We recently asked 4,000 consumers about their on-demand care preferences. Find out how well you know them in our 5-question quiz.