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Physician Fees Excessive? Doubtful.August 13, 2009

Posted Oct 04 2009 11:14pm

The survey cited below lists outrageous examples of billing from physicians and surgeons.  There are several comments to be made about this.

* First, all physicians who accept Medicare and Medicaid are paid by those payers exactly what Medicare and Medicaid dictate.  Not more, regardless of the amount charged.

* Second, almost all private insurers, if a doctor is approved by them, are paid exactly what those private health insurers and plan dictate.  Not more, regardless of the amount of charged.

*  Third, it is true, that if patients go “out of plan” to physicians, surgeons or facilities that are not approved, their health insurance will most likely pay not more than the standard rate, and in many cases they pay less precisely to incentives subscribers (patients) to stay in a contracted network of providers and facilities.

* Fourth, in cases where patients have willfully gone out of plan on their own, they must realize that they may well be liable for the entire charge from the physician, surgeon or facility.  That is a fact and they should be aware of that going in – the old adage, ‘let the buyer beware’ – would be well to remember here.  All health insurers and plans routinely warn their subscribers about this.

* Fifth, in many of the cases cited, the billings are displayed to reflect their over charge versus Medicare, as opposed to Medicare’s underpayment as compared to the market based rates.  It is not at all uncommon for charges to be 2 or 3 fold higher than Medicare rates, as Medicare, on average, pays about 35% of the market rates charged for physician and surgeon services.  For hospital services the rate is closer to 25% and for Medicaid the percentages in almost all states are even worse. In NO case should these charges be considered over charges.  It is a fact that private health insurers have been following Medicare and Medicaid rates for decades.  So while they underpay the vast majority of legitimate providers, their CEO’s and executives get outrageous bonuses and salaries.

* Sixth, in cases where charges are truly egregious, those physicians and surgeons should be reported to the state medical society, state medical board, local county medical boards and society, as well as the medical staff organization of the facility where a procedure was performed.  Additionally, consumers can report what is felt to be an exorbitant charge to the Better Business Bureau, State Attorney General’s Office and the like.  Physicians, surgeons and facilities that take advantage of the public should be scorned as they are not acting within the professional standards endorsed by all mainstream, recognized, legitimate medical organizations.

In the end, we have many issues to address, but this study, while helpful in some respects, is really designed to attempt to lay blame for lack of health insurance coverage elsewhere, when it fact it is clear that underwriting practices by health insurers and health plans are to blame for a large portion of the issues related to the uninsured and underinsured . . . jomaxx

Survey Finds High Fees Common in Medical Care so says survey sponsored by America’s Health Insurance Plans

A survey sponsored by America’s Health Insurance Plans in which insurers were asked for some of the highest bills submitted to them in 2008. The group, which represents 1,300 health insurance companies, said it had no data on the frequency of such high fees, saying that to its knowledge no one had studied that. But it said it did the survey in part to defend against efforts by the Obama administration to portray certain industry practices as a major part of the nation’s health care problems.

The health insurers, saying they felt unfairly vilified, gave the report to The New York Times before posting it online on Tuesday, explaining that they wanted to show that doctors’ fees are part of the health care problem.

The group said it had used Medicare payments for comparison because Medicare was so familiar and payments are, on average, about 80 percent of what private insurers pay.

But Dr. Robert M. Wah, a spokesman for the American Medical Association, said there was another side to the story: insurers’ low payments to doctors who enter into contracts with them and the doctors’ difficulties, in many cases, in getting paid at all. That is why, he said, doctors may simply abandon insurance plans. Then patients end up with extra fees because they have to go outside their networks.

Survey Finds High Fees Common in Medical Care –

The Value of Provider Networks And the Role of Out-of-Network Charges In Rising Health Care Costs: A Survey of Charges Billed By Out-of-Network Physicians –


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