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-- Does an insurance policy purchased through the exchange pay the doctor less than it would if the policy is purchased directly from the insurance company (or an independent agent)?
-- If so, why? The premium I'm paying for my Humana policy (purchased through the exchange) is the same premium quoted on the Humana website.
Premiums for the subsidized plans are predicated on reimbursement rates the insurance company has with its contracted providers. These negotiated payment rates may be lower than an unsubsidized plan purchased off the exchange, translating to lower premiums for exchange policies.
The presumption is exchange buyers may be sicker, thus, more expensive overall. Therefore, the narrower networks and lower reimbursements to compensate for the potential larger expense. However, none of the plans can query on pre-existing conditions which is where the real risk lies.
In your case, Humana has determined whether policies are bought on or off the exchange, their risk doesn't change. Other insurers may differ.
Pre-existing conditions is a biggee. Without that data, the insurance companies are
operating blind. In the past, insurance companies abused their right to deny/rescind policies on the basis of real and phantom pre-existing conditions. So, now they can't screen at all.
From what I heard on C-Span yesterday, the expectation is premium increases for next year will be well within the lower range of what has been done in the past pre-ACA. For now, ACA does not have these insurers running scared.
On that AZ doc not taking a patient, he needs to contact BCBS and remove himself as a provider for any exchange-purchased policies. The docs do run a risk on nonpayment if patient hasn't kept current on their premiums. Providers have testified at Congressional hearings raising this concern. Insurance company back office records/reconciliation on premium payments is an ongoing issue at this point.
If the AZ doc had cited premium payment as a concern, that I could understand. Refusal of the patient because she has an exchange policy doesn't make a lot of sense, otherwise - especially if he is a contracted provider for that insurance w/BCBS.
Last edited by Ariadne22; 04-26-2014 at 10:34 PM..
-- Does an insurance policy purchased through the exchange pay the doctor less than it would if the policy is purchased directly from the insurance company (or an independent agent)?
-- If so, why? The premium I'm paying for my Humana policy (purchased through the exchange) is the same premium quoted on the Humana website.
-- Do my doctors know whether I purchased my policy directly or via the exchange or independent agent?
-- If so, how do they know? Is there some kind of code or number on the policy stating where it was purchased?
Some of the plans are paying less to doctors. The docs know how much they are getting for these plans compared to group plans.
The insurance company keeps more of your premium.
Some of the ID cards will have the Bronze-Silver-Gold designation on them. The gigantic deductibles are also a giveaway.
The group plans have group numbers on the ID cards and may identify the employer, especially if it's a big one. The Blue cards for state employees in Georgia say so right on the card, for example: SHBP for "State Health Benefit Plan"
This is from last year, but it's from the Kaiser Health News, not an anti-Ocare site ---
"Many doctors are disturbed they will be paid less -- often a lot less -- to care for the millions of patients projected to buy coverage through the health law’s new insurance marketplaces. Insurance officials acknowledge they have reduced rates in some plans, saying they are under enormous pressure to keep premiums affordable. They say physicians will make up for the lower pay by seeing more patients, since the plans tend to have smaller networks of doctors".
Also, I saw somewhere, No Link, that it's easier for doctors to get stuck for bills owed by subsidized patients in exchange plans who don't pay their premiums.
Patients in exchange plans who are not used to having insurance may balk at paying deductibles and copayments, too. The deductibles can be scary high for these plans, even if the premium is subsidized.
If a doc sees a patient, the patient has not paid anything toward his deductible, the plan pays nothing because the patient has to meet his deductible first, and the patient refuses to pay, the doc gets nothing.
This could happen with any patient on any insurance plan, but folks are used to $250 deductibles, not $2500.
If a doctor turns patients away because they are on an individual health plan, they must think the ACA is really Medicaid or they have some other mistaken idea about their reimbursement.
I assure you that medical practices know exactly how much each plan pays. They have to post every single payment to the appropriate patient account.
Some of the ID cards will have the Bronze-Silver-Gold designation on them. The gigantic deductibles are also a giveaway.
You are correct.
For a long while now, docs have been collecting copays at the time of the visit. Indeed, the high deductibles can or can't be an issue, depending on the service being provided. Some ACA plans with large deductibles still provide for 'reasonable' copays $20/$50 for unlimited office visits - even those not preventive or the standard '3 visits' mandated by the ACA. People with chronic ailments requiring frequent visits to specialists should buy one of those plans - preferably one which is HSA compatible. In my view, anyone with a high deductible plan should have a credit card and/or HSA to cover their nonpreventive and unexpected expenses.
Many first time entrants into the private health insurance market, of course, won't know most of this, won't have any savings, and will find the premiums and deductibles impossible to pay. I don't have a lot of confidence in the 'navigators' to have helped these people choose plans they would be able to maintain long-term. I foresee a lot of drop-outs over time. This is where the docs could get stuck if the insurer's back office is not running well.
Doctors can't be forced to take any insurance. It's his choice and I ok with that, there is plenty of other doctors that will gladly accept new patients...
In the America of my youth, there were Doctors who wouldn't see black Americans. If they wanted treatment they either had to seek out a colored doctor whoi got his degree at a Negro College like Howard University or a traditional healer who had no medical education. This lead to a tragedy when the black American medical researcher (on the faculty of Howard University Medical School who pioneered whole blood transfusions died in the South on a personnal trip. He had an auto accident and died because no local doctor would see him and so he bled to death. The sort of behavior was found to be shameful and unacceptable and we put a stop to it. How is picking and choosing based on net wealth any different?
Medical Doctors are part of a special profession which takes a long time to master and practice at a standard expected of this profession. Doctor's when they graduate swear the Hippocratic Oath. It says nothing about only treating patients you like or billing them up the Kazoo. Like most non-doctors I place tremendous trust in a doctor and accept his diagnosis without question. There is no other profession I would consider doing this. A doctor in it only for the money or prestige violates my trust.
In the America of my youth, there were Doctors who wouldn't see black Americans. If they wanted treatment they either had to seek out a colored doctor whoi got his degree at a Negro College like Howard University or a traditional healer who had no medical education. This lead to a tragedy when the black American medical researcher (on the faculty of Howard University Medical School who pioneered whole blood transfusions died in the South on a personnal trip. He had an auto accident and died because no local doctor would see him and so he bled to death. The sort of behavior was found to be shameful and unacceptable and we put a stop to it. How is picking and choosing based on net wealth any different?
Medical Doctors are part of a special profession which takes a long time to master and practice at a standard expected of this profession. Doctor's when they graduate swear the Hippocratic Oath. It says nothing about only treating patients you like or billing them up the Kazoo. Like most non-doctors I place tremendous trust in a doctor and accept his diagnosis without question. There is no other profession I would consider doing this. A doctor in it only for the money or prestige violates my trust.
Doctors are also business owners...
If you don't like a doctor because of her or his stance then don't see her or him. Based on what I read, his reimbursement is the same so he sounds like a stupid businessman. There isn't a law against being stupid.
In the America of my youth, there were Doctors who wouldn't see black Americans. If they wanted treatment they either had to seek out a colored doctor whoi got his degree at a Negro College like Howard University or a traditional healer who had no medical education. This lead to a tragedy when the black American medical researcher (on the faculty of Howard University Medical School who pioneered whole blood transfusions died in the South on a personnal trip. He had an auto accident and died because no local doctor would see him and so he bled to death. The sort of behavior was found to be shameful and unacceptable and we put a stop to it. How is picking and choosing based on net wealth any different?
Medical Doctors are part of a special profession which takes a long time to master and practice at a standard expected of this profession. Doctor's when they graduate swear the Hippocratic Oath. It says nothing about only treating patients you like or billing them up the Kazoo. Like most non-doctors I place tremendous trust in a doctor and accept his diagnosis without question. There is no other profession I would consider doing this. A doctor in it only for the money or prestige violates my trust.
The problem is that doctors now must also be businessmen. If they are not, they will have to close up shop. Driving down reimbursement below what it costs for overhead leaves the doctor with no income at all. Even the most altruistic physician has to take down his shingle if that happens. He cannot provide any care at all if he has to fire his staff and has the lights cut off.
By the way, orthopedists provide a tremendous amount of uncompensated trauma care through the ER. They have to come when they are on call even if the patient has no insurance or money at all.
This refers to all physicians, not just orthopedists:
"When asked to estimate the amount of uncompensated care that they personally provide — not their entire group — in a year, respondents reported the following:
• Less than $5000 — 14.6 percent
• $5001 to $15,000 — 10.6 percent
• $15,001 to $25,000 — 12.6 percent
• $25,001 to $35,000 — 6.5 percent
• $35,001 to $50,000 — 16.4 percent
• $50,001 or more — 39.3 percent"
"The report includes responses from 13,575 physicians. The survey was conducted on behalf of The Physicians Foundation by Merritt Hawkins and completed in September 2012."
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