Honored Social Butterfly

When Medical Providers Don"t Participate in Health Insurance Plans - SURPRISE !!! 


Every politician condemns the phenomenon of “surprise” medical bills.


Last week, two committees in the House were marking up new surprise billing legislation. One of the few policy proposals President Donald Trump brought up in this year’s State of the Union address was his 2019 executive order targeting “balance bills.” In the Democratic debates, candidates have railed against such medical bills, and during commercial breaks, back-to-back ads from groups representing doctors and insurers proclaimed how much the health care sector also abhors this uniquely American form of patient extortion.


And yet, no one with authority in Washington has done much of anything about it.


Here’s why: Major sectors of the health industry have helped to invent this toxic phenomenon, and none of them want to solve it if it means their particular income stream takes a hit. And they have allies in the capital.



History -

Forty years ago, when many insurers were nonprofit entities and being a doctor wasn’t seen as a particularly good entree into society’s top 1%, billed rates were far lower than they are today, and insurers mostly just paid them. Premiums were low or paid by an employer. Patients paid little or nothing in copayments or deductibles.


That’s when a more entrepreneurial streak kicked in. Think about the opportunities: If someone is paying you whatever you ask, why not ask for more?


Commercial insurers as well as Blue Cross Blue Shield plans, some of which had converted to for-profit status by 2000, began to push back on escalating fees from providers, demanding discounts.


Hospitals and doctors argued about who got to keep different streams of revenue they were paid. Doctors began to form their own companies and built their own outpatient surgery centers to capture payments for themselves.


So today your hospital and doctor and insurer — all claiming to coordinate care for your health — are often in a three-way competition for your money.


As the battle for revenue has heated up, each side has added weapons to capture more: Hospitals added facility fees and infusion charges. Insurers levied ever-rising copayments and deductibles. Most important, they limited the networks of providers to those that would accept the rates they were willing to pay.


Surprise bills are the latest tactic: When providers decided that an insurer’s contracted payment offerings were too meager, they stopped participating in the insurer’s network; either they walked away or the insurer left them out. In some cases, physicians decided not to participate in any networks at all. That way, they could charge whatever they wanted when they got involved in patient care and bill the patient directly. For their part, insurers didn’t really care if those practitioners demanding more money left.


And, for a time, all sides were basically fine with this arrangement.


Now they have become impossible to ignore and there seems to be even some new players like ambulance companies and life-flights who are opting to stay out of network plans.


The Battle:

These practices are an obvious outrage.  But No one in the health care sector wants to unilaterally make the type of big concessions that would change them and reduce their payments (doctors/hospitals) or have them pay more (insurers). 

  • Insurers want to pay a fixed rate.
  • Doctors and hospitals prefer what they call “baseball-style arbitration,” where a reasonable charge is determined by mediation.
  • Both camps have lined up sympathetic politicians for their point of view.

States are passing their own surprise billing laws, though they lack power since much of insurance is regulated at a national level.


So what is the answer?  It's hard to imagine another issue for which there is such widespread consensus. 

  • Two-thirds of Americans say they are worried about being able to afford an unexpected medical bill — more than any other household expense. 
  • Nearly 8 in 10 Americans say they want federal legislation to protect patients against surprise bills.

It is not quite that easy - even traditional Medicare has but a couple of remedies:

Disclosure to the beneficiaries for doctors not in the Medicare system and forced compliance if the hospital where they work accepts Medicare funding.


Even if we invent a new healthcare insurance system - like a public option or a for-all type plan - how would the negotiations or rules change for providers in the private marketplace to make them accept (whatever) payment and not be a surprise to the patients needing their service?

Regular Contributor

Hello Gail .. it is an outrage to have insurance companies dictating what is allowed and what is not.
Just recently I had Medicare deny a claim for having a blood test that my doctor said I should have done. I called and asked why my claim was denied and was told they (Medicare) did not deem it necessary that I should have this test done. Really? Since when does Medicare have an MD? As it turned out, I needed medication due to results found from the same blood test. It's a disgrace. We all have worked hard all of our lives to be able to have some security in our later years. Medicare and Social Security is NOT a gift.. It's been paid for!!! Keep up the good fight

Honored Social Butterfly



Your post has little to do with this thread - but I guess in a way, your problem is a surprise but one that has (traditional) Medicare rules in place for just such a situation.


Medicare (Part B) Covered Services

anything that is not listed or you can't find, to the right there is a place where you can insert a description and do a search.


Medicare states that services have to be "medically necessary".  Your doctor substantiates this necessity by the diagnosis or potential diagnosis codes that he also sends to them.  If there is a test to procedure that he thinks might not be covered, he should have had you sign a Medicare Advance Beneficiary Notice


from the link ~

You may get a written notice called an "Advance Beneficiary Notice of Noncoverage" (ABN) from your doctor, other Health care provider, or supplier if you have Original Medicare and your doctor, provider, or supplier thinks Medicare probably (or certainly) won't pay for the items or services you got. 


However, an ABN isn't required for items or services that Medicare NEVER covers.


The ABN lists the items or services that Medicare isn't expected to pay for, along with an estimate of the costs for the items and services and the reasons why Medicare may not pay.


You’ll be asked to choose an option box and sign the notice to say that you read and understood it. You must choose one of these options:

  • Option 1: You want the items or services that may not be paid for by Medicare. Your provider or supplier may ask you to pay for them now, but you also want them to submit a Claim to Medicare for the items or services. If Medicare denies payment, you’re responsible for paying, but, since a claim was submitted, you can appeal to Medicare. If Medicare does pay, the provider or supplier will refund any payments you made (minus the copayments and deductibles you paid).
  • Option 2: You want the items or services that may not be paid for by Medicare, but you don’t want your provider or supplier to bill Medicare. You may be asked to pay for the items or services now, but because you ask your provider or supplier to not submit a claim to Medicare, you can’t file an appeal.
  • Option 3: You don’t want the items or services that may not be paid for by Medicare, and you aren’t responsible for any payments. A claim isn’t submitted to Medicare, and you can’t file an appeal.

An ABN isn't an official denial of coverage by Medicare. You have the right to file an appeal if payment is denied when a claim is submitted. 


Appeals or redeterminations are done in a step fashion - if you do the 1st one and it is still denied, you can continue to go up the hierachy of reviews.   (see Appeals Form at this link) 


One other point is that on just about all services that are covered by Medicare, there is a disclaimer that says: "usually" pays.  There are also other test where Medicare may pay for them within a certain time frame (like every 24 months) and no more unless there is substantiated reason submitted by your doctor for Medicare's determination.


Sometimes that term "Medically Necessary" means different things to different people - especially the patient having to pay out of pocket. 


Course then there are always errors too like the doctor using incorrect codes.


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Honored Social Butterfly

I hear you loud and clear Janice!!!
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