Why did my anesthesiologist get paid in full for their bill while my doctor has to give a 50% discount?

I will start off with a statement that I am not picking on anesthesiologists because the same question could be asked about radiologists, pathologists, emergency medicine doctors, and other specialists who work only within the hospital setting.  There are reasons that doctors are paid differently even for the same services.  The hospital based physicians in particular though do sometimes get paid more on a percentage of charges than do other providers and several factors weigh into that as well.

I will preface the rest of the blog post by sharing that I am writing based on how it works in many states, there are exceptions around the USA where hospital based physicians work directly for the hospital and the compensation structure paid by the insurance companies is different as well. In Texas all physicians providing clinical services are in their own practices which are separate from the hospital. Thus they or their practice bills and collects revenue for the services provided separately from the hospital’s charges and collections.

Generally we seek to get care at the lowest cost, so we typically all seek “in-network” care. This means we go to providers who are contracted with the insurance company. In exchange for the provider being in the network for any given insurance carrier, they give a discount off their charges. From a practical standpoint they really agree to the fee schedule offered by the carrier or negotiate rates they will accept. Generally most providers must accept the rates offered by the carrier.

Some providers do get exceptions to the carrier’s standard fee schedule. One set of providers who may get an exception is those who have a proven track record of providing cost effective care with good outcomes. Large groups who are critical to the carrier’s networks may get negotiated rates. Hospital based physicians, such as the anesthesiologists and radiologists, often because they have exclusive arrangements at specific hospitals are also able to negotiate rates.  Of course not all physicians agree to contract with the insurance carriers and this leads to out of network care issues.

Often, but not always, in a hospital based setting, physicians who only work in the hospital will be paid at the “in-network” rate even when they are not contracted. Again, I stress this is definitely not a guaranteed situation, but it does happen.   This is exactly the situation where you will sometimes see payments to anesthesiologists, radiologists, pathologists, and emergency medicine physicians getting paid more than you would expect for a contracted provider.  It is because they in fact are not contracted but are being paid at the in-network level.  In some cases, primarily emergency care, the provider may in fact get their full charges paid.

The hospital based physician charges and out of network issue is one that many of the carriers fight on a regular basis because some of these hospital-based physicians to charge rates well above what other providers are paid for similar services. This issue is something that is a big deal to the carriers because paying 2-3-4 times what others are paid for the same services does end up costing everyone more in terms of higher premiums.  One technique used by carriers now, where permissible is to limit payment to the same amount paid by Medicare for non-network providers.  (Those providers who refuse to accept Medicare Assignment.)

These limits on payment may result in the patient being balance billed, however the insurance company may make whole patients/members who had no choice but to use the out-of-network physician.  These are the cases where you can expect to see the higher level compensation paid to physicians.  So collectively higher negotiated rates with the carrier and payments to non-network-providers in order to hold the member harmless make up most of the higher payments to hospital based physicians.  The other reason you may see full charges paid is that the provider adjusts their charges based on contracts with carriers and only charges what is due by the carrier, automatically writing the difference off as a contractual allowance.

Generally it is a rare circumstance where you will see a provider paid their full charges by an insurance company, but it does happen. The above information should have shined some light on why that happens with hospital based physicians.  If you need help with Health Insurance In Texas so you can get hold of network discounts contact us.

At what point does Medicaid pay for my nursing home?

Many do not understand that Medicaid is not there to pay for nursing or other long term care for everyone. There are many very significant limits that come into play with Medicaid and its coverage of long term care needs.  This is one reason it is important for those with assets to make plans and consider the use of various insurance products to ensure you have adequate coverage to pay for or at least help cover the cost of long term care.

Medicaid is a program established thru joint funding by the US Federal and each State’s government.  The program is tax payor supported and as a result has a somewhat limited budget. Couple that with the fact not all providers agree to accept payment from Medicaid. That may significantly limit your ability to find a place to secure a nursing home room. A further consideration related to government paid care is that Medicare does not cover long term care.

When you get to the point you need long term care, you have to decide what facility you want to use.  You will need to know how the care will be paid in order to truly assess what facility you can use. Most facilities accept only select forms of payment.  Thus, generally to get into a facility you need to be paying cash or have a long term care policy.  Once you are in and are depleting your cash and other assets to pay for your care you “spend down” towards Medicaid eligibility.

Medicaid Eligibility varies by state but generally speaking is only a couple thousand in assets plus a house and auto. Generally speaking that is not enough assets for folks to maintain their living standard.  It is a bigger issue when this involves a couple because the, spend down or Medicaid eligibility level will impoverish the spouse.  There are also laws on the books that prohibit giving away the assets to others within five years of when one wants to be deemed eligible for Medicaid.  Thus spending down to Medical eligibility is one way to get Medicaid to kick in.

Once you have met the poverty requirements to get Medicaid, then you meet the medical requirements to require nursing home care and then you have to begin looking for a nursing home bed available for Medicaid payments. These beds are scarce as few facilities want to accept the low rates paid by Medicaid and the other associated requirements set forth by the government.  So now you are eligible for Medicaid to pay for your care but are not necessarily able to find a bed in which to live.

The question most asked is when will Medicaid begin paying for my nursing home care, the answer a bit long but comes down to when you meet poverty requirements and when you can find a Medicaid certified bed that is available. Getting both to fall into place is not as simple as it sounds, but is achieved.

Does the government want me to sign up for a Medicare Advantage Plan?

I’ve been asked this question several times by those on Medicare. In fact no, the government is not requiring or pressuring anyone to sign up for a plan. They have created these plans which are run by private insurance companies, as an option to the Original Medicare Plans.  Deciding to sign up for one of the Medicare Advantage Plans is completely your choice.

The government does have rules which govern marketing of Medicare Advantage Plans. One thing which is specifically forbidden is telling people that the government wants them to sign up for a plan. Further the government does not endorse any plan, or suggest that you pick one over the other.  This goes for the Medicare Drug plans as well as the Medicare Advantage Plans. These marketing rules are intended to help protect Medicare beneficiaries from those who only care about pushing thru a sale instead of helping the beneficiary make the best choice based on their needs.

For those who do choose a Medicare Advantage plan they should know they still have all the rights and responsibilities associated with having Original Medicare.  You will still have Medicare, however instead of the government paying the bills for your care, your Medicare Advantage plan and you share in the cost of your care.  With most Medicare Advantage Plans you will need to remain within the network of providers maintained by the Medicare Advantage Plan, although some are actually set up with open networks allowing any Medicare physician to see you as an “in-network” provider.

Be sure you understand the Medicare Advantage plan before signing up, or consider taking a Medicare Supplement Plan and a Drug Plan along with your Original Medicare.  Also remember the government does not force anyone onto the Medicare Advantage plans.

For expert advice in selecting the right Medicare Supplement Plan in Texas give us a call.

Why does the hospital want me to make a deposit before I get my care?

At the present time, hospitals and many surgeons and other providers look at your health insurance benefits before they see you for care. Part of what they look at is; where is this person in meeting their deductible and would they owe a lot of money for care received if it is billed to the insurance company first?  Why do they do this?  All businesses want to be paid for the services and goods they provide. Just like you pay for your pizza now on-line ahead of its delivery, quite a bit of healthcare is now paid before or at the time of delivery.

Unlike when you go to the doctor’s office and pay a co-payment (if you are on a PPO non H.S.A.) based plan, for other care needs the cost typically will vary. The providers know what they will get paid usually and generally also know what services will be provided. That is how they determine what your deposit should be. When at the doctor’s office where a co-payment is due that is a fixed amount based on the plan’s benefits so the co-payment is handled a bit differently because it is a set fee paid not a deposit.

When you have a large deductible that is not yet met, the providers want to ensure they don’t provide you with either uncompensated care or provide you with a free loan. In order to protect from these situations they require, and the insurance carriers typically allow, a deposit against the cost of the care.  The deposit should be no more than you would owe based on how much of your deposit is already met.  You should not be asked to fund the full procedure with refunds coming after insurance processing of the claim, unless that amount is less than what you still owe on your deductible.

You should always know how much you still owe towards your annual out of pocket maximum. Keep in mind with most plans co-payments do not count towards these maximums, they only capture deductible and co-insurance. It should be easy for you to track and needs to be tracked to make sure your and the insurance carrier numbers match.  Remember in-network and out-of-network maximum out of pocket costs add up in different buckets, so often if you use services in one of the other it does not necessarily fill both buckets.

If you are going to the hospital for elective surgery, scheduled well ahead of time, you will almost always spend some time at the hospital ahead to conduct pre-operative reviews. These reviews are medical and financial.  At this time the hospital staff will conduct a check of benefits and see where you are with regard to meeting the maximum out of pocket.  They will then discuss with you the expected cost of care and where your personal costs are expected to be. At that time they will ask you to pay a deposit for your expected out of pocket costs.  They may be able to work out a payment plan, and the best time to ask for such is at that time.

Healthcare is expensive to obtain and for most providers to provide. To that end the providers are just ensuring they are going to get paid for their services and goods provided. That is why you are asked to pay a deposit for care in many cases.