The Emergency Room was in my network; why wasn’t the doctor? In network, out of network, why is this so confusing and complicated. As a healthcare consumer, it is getting harder and harder to trust that our healthcare costs will be properly paid by our insurer. Why should we have to worry about this anyway? Patients who want to use an in network doctor can usually go through their insurer but what happens when the place you go to is in the network yet your doctor isn’t. Have you been bamboozled; well kind of. The truth is, the world of insurance companies, and plan participation is the world of got ya’s. Why should you ever have to worry about this? The other truth is, whatever the insurer can deny or put toward their high deductibles for out of network care, or deny it altogether under an EPO such as Horizon’s Omnia works for them, not for you. Doctors do not accept in network rates for various reasons including unacceptably low reimbursements, too many requirements, plans not paying clean claims or just that it is more profitable for them not to participate. The truth is, healthcare has become too complex and the large healthcare systems are taking over with the help of the large insurers, which leaves out two important people; you and your doctor who are caught in the middle. All of this could be eliminated by going with a single payer like Medicare for all. Currently, 70 + million people are under Medicare, are happy with it and all hospitals and most doctors are currently providers under the system, giving it the largest network. Will it solve all of our problem in our healthcare system; no, but simplifying the system is a start. The systems need a lot of work and too often, healthcare systems are way too complicated due to regulation and the way hospitals bill. Perhaps global fees for certain conditions may be a better way to reduce costs, and one payer will have an easier time doing it with a simpler billing system. Is fee for service really bad? It depends on the doctor and the procedure(s). Often a complicated case requires more work, and unlike years ago when a doctor charged for their time, the doctor just charged for that time and their expertise with a reasonable charge for the service. When Medicare came along in the 1970’s, a doctor sent in a bill and got paid. Unfortunately, they began to notice that if they sent in a larger bill, that got paid as well and they just made up charges that were higher and got paid as well. This clearly led to healthcare inflation, and the system has blown up from there. The current system with its codes, complicated diagnostics and oversight is too complicated. Fraud while not a huge problem takes advantage of the systems complications and exploits them. Hospitals with their chart master systems have been able to charge you much more as a cash patient than an insurance patient would pay. This is clearly wrong. A doctor who is out of network often prices their service much higher than is rational, which is why often we feel betrayed when a doctor in an in network facility sends you an out of network bill. This is clearly a problem as more carriers sell us high priced EPO products that have no out of network benefits, which means that the charge is our problem, and is routinely denied by the carrier. The problem is made worse because those who do not have small business cannot purchase any plans with out of network benefits either on or off the exchanges, something that is unfair and if they could, the benefit would be marginal. While it is true that the new Trump administration would favor maintaining insurance carriers at the front of our systems, the truth is that even across state lines, insurers have shown themselves to do things inefficiently, not using healthcare logic that is cost effective. This simple fact has made it more expensive for all of us, while they try to enrich their shareholders with strategies that make sure we pay more as a society for care that is often more expensive, and not as good for us than what other countries have. This of course leads us to the idea of one payer, called Medicare. This would eliminate the in and out of network travesty by giving us all good coverage which is the same from state to state, without insurers taking their 20% which goes towards administration, image advertising, claim denials and removes the motive to make changes to the system that cost us more. A number of years ago, Medicare introduced a system called RBRVS, which looked at the work done and added a multiplier for the service which helped level the playing field to reimburse doctors. Most primary doctors were happy with it, most specialists who were used to being paid more for what they did were not. With some adjustments, this is likely a fairer way to pay healthcare providers. While this will not fix what is clearly wrong, it is a start. Simplifying what doctors need to do to get paid clearly would help lower their costs, give them one set of rules and the reduction of costs by a single payer would help us save money. Once in place, changes can be made to simplify the systems as well which is too complicated. Just like the current system with its cost problem has taken years to develop, fixing it is going to take years as well. From the standpoint of a patient, having one insurer, with doctors being in it and being paid fairly is what logically most of us should want, but are we logical? Are our doctors doing their electronic medical records for compliance so they can better take care of you, or are they doing it so the insurer cannot claw back the money they use to run their practice; something to think about during your 3 minute doctor/7 minute doctor typing into the health record visit. Could this be why more doctors who work in systems are choosing not to be “in network”? Recently, the NY Times had written a column in their health section regarding this growing problem. Read about it here.