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Doctor Reimbursements For Patients Covered By “State Exchange Policies” Dropping Even More Doctors Below What Medica

Posted Nov 21 2013 11:29pm

Back in November of 2012, a year ago I reported that in California that along with doctors automatically being opted in with Blue Cross, their reimbursement was looking to be around 30% less than what they receive from a standard commercial policy.  Somebody just asked me about that the other day who signed up and I shared that information as and far as I know unless doctors in California sent a registered letter to opt out, they are automatically in network.  This also recently changed a bit as doctors in the rural areas said no and Blue Shield on their contracts had to kind of back down.  Too few doctors agreed to the 30% drop so Blue Shield had to revise their contracts allowing an opt in instead of the opt out to see exchange patients.  I am not sure exactly what happened to the Blue Cross side of this. 

Blue Cross in California Automatically Opts Doctors In for Insurance Exchange Participation And Reimbursement Looks To Be Around 30% Less Than They Receive Now For Individual Policies - Employer Provided Insurance Is Not Affected

So now we have the same situation hitting New York and maybe even harder hit for the MDs.  United has very complex contracts and has been paying doctors in some areas way less than Medicare already as the AAFP confronted them with a while back.  Insurers don’t want reduced profit margins that’s for sure.  The New York folks won’t get the same treatment as California did though as United is different, just look at all the doctors they are firing.  

The AAFP Confronts United Healthcare On Reimbursements, Some Are Below Medicare Rates In Parts of the US–Payment Algorithms/Formulas Calculated Deep Within IT Infrastructures Do the Job

Everyone compares this to the Medicare roll out but let me tell you we did not have all this connected data and executing algorithms back then and it will not be something that will settle down as this will not go away.   You cannot have a “static” formulated law and have insurers with math models and algorithms that can change by the minute based on profit…it will all tumble in time.

One doctor commented and stated that in south Florida United is paying  paying 75% of what Medicare pays using a 2001 Medicare fee schedule and the company keeps telling everyone they are out to reduce MD compensation with their press releases sometimes. 

UnitedHealthCare Looks at Doctor’s Pay for Savings, Nothing New There Been Doing It for Years But Keep In Mind We Have the Annual Medicare Cut Fix on the Floor Again with Congress–Timing?

The only relief that doctors did receive earlier this year in the reimbursement area was a decision from the Supreme Court that now allows doctors to group together to litigate which United Healthcare fought tooth and nail to not allow this as it has been in their contracts for years to have one doctor against the big corporation.

US Supreme Court Rules Physicians Can Work As A Group To Fight Unfair Business Practices of Health Insurers–Victory Over United Healthcare (Oxford Subsidiary)–Context Once Again With Contracts

Some of the rates bottoming out in some areas are even less than Medicaid.  If that were to happen in California which has like the lowest in the US reimbursement rates, there would be very few doctors to see.  It’s the bottom of the barrel, so no more goes the balance of commercial and Medicare rates, and actually that was gone a long time ago.

Something of interest United their new biggest single share holder, Brazilian Billionaire Edson de Godoy Bueno who came into power and has a board seat when United bought Amil, the largest HMO in Brazil. 

United Healthcare Negotiated to Buy 90 Percent of the Largest Managed Care Provider in Brazil, Where Insurers Can Own Hospitals and Physician’s Practices

In addition United wants to make even more money consulting and being the implementer for the biggest medical records companies in the US, an outsourcer. 

United Healthcare (Optum Insight Subsidiary) Wants To Be Your Allscripts, Epic And GE Centricity EHR Consulting Service Starting With Implementation And Beyond

I say watch United and their contracts and deals as they have some scars from the past to include the big AMA class action suit to where by design with “math models” and computer algorithms, they under paid out of network charges for 15 years and all the other big carriers licensed their model and did the same and there’s still tons of lawsuits out there. 

AMA Announced Settlement of Class Action Suit of $350 Million

You can also go back and re-visit the biggest derivatives settlement to date with back dating stock to where the former United Healthcare CEO, William McGuire  resigned and took the hit but if you read the court documents, their current CEO was doing the same thing but dollar amount was smaller.  BD


Insurers are slashing payments to medical practices in many of the plans they sell through the new health-law marketplaces—sparking worries that Americans signing up for coverage will have fewer doctors to choose from if low fees spark an exodus from the plans.

UnitedHealth Group Inc. UNH +1.29% sent some New York City physicians contract amendments as recently as this month setting rates well below what doctors normally see from private insurance, including less than $40 for a typical office visit and about $20 for reading a mammogram, according to confidential documents reviewed by The Wall Street Journal.

"We have heard from a lot of physicians the rates [insurers] are offering them are very low, and physicians are questioning whether they are going to participate," said Sam Unterricht, a Brooklyn ophthalmologist and president of the Medical Society of the State of New York.

More physicians may leave the plans as awareness of the new rates spread, doctors and experts said. Many doctors surveyed in September by the Medical Group Management Association said they weren't aware of the fees they would be offered for treating patients gaining coverage on the exchanges. Of those that had heard, 37% said the rates offered were lower than Medicare, and 18% said they were lower than Medicaid rates, according to the survey.

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