Health Care in this country is not what it used to be – let’s start off right there.
For example, a July 2014 publication through Forbes ranked the United States 11th out of the top Commonwealth Nations (UK took top spot, if you were curious). We ranked dead last in every category including quality care, access, efficiency, and cost.
According to the New England Journal of Medicine (2010), the US ranks 37th out of all nations for Overall Health. We rank 39th for infant mortality, 43rd for adult female mortality, 42nd for adult male mortality – yet, as of 2006, the United States ranked #1 for health care spending per capita.
This is one statistic not to be proud to shout ‘We’re #1! We’re #1!’
Okay, so we know that the health care industry needs to change. The rollout of the Affordable Health Care Act has proposed some solutions to correcting the health care burden: they include extending insurance coverage, decreasing the growth of costs through improved efficiency and to expand prevention and wellness programs.
While this policy has helped many who were uninsured before (including myself and my wife), the care plans that many of us can now afford are catastrophic plans, which are essentially limited to coverage for major health concerns (surgeries, major hospital visits). The benefit of course, is to have the coverage when you need it – but at the expense of a steep deductable (in the 1,000’s) which must be met out-of-pocket before the insurance company will step in; but getting care through chiropractic, dental or physical therapy, for example, will cause policy holders to dish out more money just to reach those high deductibles.
What do these increases to out-of-pocket expenses mean?
First, let me preface this by discussing in- and out-of-network benefits.
In-network providers are physicians of every health care profession (physical therapy, radiologist, cardiologist, general practitioner, nurse practitioner, chiropractor, etc.) who have contracted with your insurance policy. It means that they have agreed to receive payment at rates the insurance company has set based upon your state and location within the state (for example, benefits in Manhattan will differ greatly from those in Albany). It also means your care is limited to what the insurance company will pay (and not pay) for based on your symptoms – the doctor who treats you in essence does not ‘work for you’, they work for your insurance company.
This becomes problematic because many of these facilities increase the volume of their practices in order to offset lower reimbursement costs. Even with your co-payment, the insurance companies reserve the right to change the value of the services covered. And these offices that have contracted with your insurance company, need to make up for the difference – by bringing in more patients. So now, you are seen less like a patient and more of a statistic, or what your in-network policy will cover.
Further, many insurance companies have algorithms they use when determining YOUR care plan. That’s right. Someone who has NEVER met you, and only knows you through your policy number – has just determined that you need 8 visits for your (x-pain). This means that miraculously, your symptoms should be gone in – 8 visits. We know however, that life is not an algorithm and unforeseen complications arise. Your care plan may in fact require 10 or 12 visits – and your insurance company won’t pay those visits – so guess who has to make up the difference – you do.
Finally, say for example you see a chiropractor for lower back pain and related hip discomfort. The ideal protocol for this chief complaint would be to perform soft-tissue therapy and to mobilize the hip joint, as well as perform the chiropractic adjustment to the lower spine.
Trouble is, your in-network policy may not cover the extraspinal code (your hip), nor the manual therapy code. Meaning, you’ll get the quick-and-dirty chiropractic adjustment and be sent out of the office. Is this best practice? No, but will your in-network provider go above and beyond and treat the area? Not unless you are willing to pay for what your insurance company deems as ‘unnecessary’.
Out-of-Network providers are the very same as those listed above who have not signed an agreement with your insurance company. Although each state regulates health care fees for each profession, there is a little more leeway in terms of what is and what is not covered. Further, when you go out-of-network, you are treated more a patient should be. Specialty care is designed around the patient, not what an insurance company dictates.
Further, out-of-network providers reserve the right to charge prices for care that they know the patient needs, not what an insurance company dictates. Often, these prices are lower than the inflated insurance costs because these health care providers recognize that limited coverage equals limited results.
Deductibles and Co-Payments, or Self-Pay – What is the Difference?
To preface this, many individuals are becoming smarter health-care consumers. They are trending towards looking for physicians who deliver quality care who don’t price gouge them.
With deductibles and co-payments muddying up the system, you’ll never know when you might receive a bill down the road, months after a treatment, because ‘you were told it was covered by your insurance company – don’t worry about it.’ Individuals who go outside their network for specialty care, or choose to pay out-of-pocket get to bypass the ‘what’s covered, what’s not’ line. Instead, they are given a price – up front – and no sticky bills down the road. The fees are what the fees are – and they are often more cost effective than the medical maximum fees that insurance companies set.
Why is that?
Insurance companies set the fees, visit frequency and items of service covered. In the great state of New York for chiropractic care, for example, a chiropractic adjustment will cost you $55.00, manual therapy to treat the affected soft tissues is $45.00, and extraspinal work (any extremity) is $35.00.
Many chiropractic patients come in with co-morbidities in addition to their ‘neck and back pain’. Often we see shoulders, hips, knees, ankles, elbows and wrists – just to name a few. To treat all these areas for a singular visit is $135.00/visit. If your insurance company, for example, does not feel that they want to pay for anything other than the classical chiropractic visit – yet your body requires the extra work to accelerate healing – the patient – YOU – are on the hook for the $80.00 difference – cool, huh?
Behind the Scenes
Medical offices that utilize insurance companies often employ office billing managers to oversee payment of claims. These people are paid hourly wages to essentially ‘chase down’ claims that are delayed, denied or lost by the insurance companies. They are often on the phone for many hours on any given day – on hold – as well as wasting ink and paper to fax and re-fax claims.
Furthermore, these offices use clearinghouses as mediators between the doctor’s office and the insurance company – and they charge perclaim for their services so the billing manager won’t have to keep pulling their hair out.
In the eyes of the patient: they are seen, and their insurance is billed. The clearinghouse processes the claim. The claim is received by the insurance company. The claim is paid to the doctor. Simple, right?
Not quite. Ever look at the back of your insurance card and look at the address. It’s often one that is not even in your state, let alone the same area. This is because insurance companies are multinational and have offices and call-centers country-wide. Policies change all the time, workers are hired and fired, and so to get consistent information from a representative is often quite challenging and frustrating.
Now, these claims when processed take months to clear through. That is because they are fed into a massive database – where you are known only as a policy number. Such high volumes of claims that are being processed through the system change hands all the time as well as go through multi-level processing – errors happen all the time. Claims are denied, which also takes time to get back to the doctor’s office. Some claims (I have first-hand experience) have taken upwards of ONE YEAR for re-processing.
But wait – there’s more. Do you know how insurance companies retain their wealth? They pay out fewer policy dollars then they receive – its’ simple math: I have 3 dollars, I give you 1, therefore I keep 2. How do insurance companies do this exactly? They can do this multiple ways.
For starters, they can withhold payment for the doctor for up to 3 months. In that time, the insurance draws interest off that and many other claims nation-wide before money must be sent out. Another way they save themselves money is to outsource to SECONDARY companies.
These companies and their representatives are hired through the primary company to – you guessed it – save them money. It is their job to deny claims, or file claims for re-processing so that the primary company can collect interest on money before they have to pay out a claim.
These secondary companies receive bonuses for trimming the fat of the claims that come in.
What this means to the patient – is that once a claim is processed, it is either paid for a time until benefits are cut off; the claim is denied; or the claim is partially paid (because the insurance company didn’t want to cover all the costs) – which means your doctor’s office has to be the bearer of bad news and ask you to politely pay the difference from a visit you may have had a few months ago.
1) Increasing Deductibles
Many of us have seen our $500 annual deductibles double. Most people cannot afford top-shelf care and therefore elect to purchase cheaper, more affordable plans – catastrophic plans, or ones slightly above that. These are the people with $1,000 – 6,000 (per person) annual deductibles that must be paid out-of-pocket before your insurance company will even begin to cover some of your costs.
2) Increasing Co-payments
Remember when you had only $5 co-pay? Yeah, me either. Many policies for specialists range from $35 – $50. And that’s JUST the co-pay!
Let me paint an example:
Tom is a laborer with catastrophic insurance. His new employee policy just changed and he now has a $2,000 deductible (up from $1,000) and a $40 co-pay (up from $25); because his employer just downsized production, and the cheapest way for any company to save money is through health care trimming.
But Tom cannot afford to pay the monthly premiums that his old plan had, so he went with the cheaper option that his employer offered.
Now, Tom needs to see his chiropractor because he wrenched his low back at home working on his front lawn. He picks up the phone and calls his health care provider (i.e. Blue Cross Blue Shield) and asks for his in- and out-of-network benefits for doctors in his area.
His carrier is thrilled to announce that he has in-network coverage (no carrier recommends any out-of-network provider because they are not policy-assignees, so they have no record).
Now, let’s see what happens to Tom’s hard-earned dollars. Since his policy and co-payments have changed, he will be paying more up-front costs. The insurance company did tell Tom he had coverage after all, but his personal out-of-pocket costs went up due to his new insurance policy.
So Tom visits the chiropractor and it’s the beginning of the year and Tom has not seen any other health care provider in his network. This means, that every doctor he sees will eat into that $2,000 deductible. If Tom does not see any health care provider for the year, he would spend the $2,000 at the chiropractic office. The doctor evaluates Tom and tells him he’s looking at a 20 visit treatment plan over the next few months to help correct his source of pain. Tom is happy he has found out what’s wrong with him and is happy to begin treatment.
So, adding up the costs: $125 – initial evaluation + 20 x ($55-chiro + $45-manual therapy + $35 – Tom’s hip) = $2,255.00.
[Tom paid for the initial evaluation ($125) and 14 chiro visits at $135.00, his deductable was met at 2,015. He then paid the remaining #6 visits at $40/visit (co-pay) for a total payment of: $2,255.00]
Tom’s insurance plan covered #20 visits, and he was cut off. He was not interested in paying more for care, so he stopped visiting.
Three months later, Tom receives a bill from said chiropractic office. Tom is furious to discover that his insurance company only covered 100% of billable services at the office until he was cut off after 12 visits. This is because Tom’s primary insurance carried over to a secondary policy, which did not cover these new visits. Tom’s owes for 8 visits at $135 minus his $40 co-pay. Tom’s surprise bill comes to: (1,080 – 320 = $760). Tom has now paid $3,015.00 for 20 visits of chiropractic care.
Clinics that are out-of-network and those that offer self-pay, or cash options recognize these insurance pitfalls. They are sympathetic to the outrageous prices that insurance companies set. They also know that insurance companies pay percentages of fees, which is when patients receive payment notices from their clinics for money owed.
So, while patients are trending towards spending their health care more wisely – they begin to look for offices that cater to the patient, not their insurance policy.
From a chiropractic perspective, best-practice care is not a quick 5-minute ‘click, snap, pop; in-and-out’ visit.
From a physical therapy perspective, best-practice care is not a 15-minute hot/cold pack; 15 min physical therapist session; 15-20 min exercise session with an aid whose not really paying attention; 15 minute ice-pack cool-down.
But, unfortunately this is what the health care model is trending towards for those who are in-network. They are patient mills because they have to be. They need bodies-in, bodies-out every hour on the hour.
Out-of-network and self-pay offices are different in that they provide the care patients need and deserve. Visits are based on symptom management and corrective care. They have a vested interest in getting you better so that they can get back to doing the things that are truly passionate about.
Additionally, should you have a relapse at any point in the future, down the road, there are no reactivation fees. Care plans are updated and modified if new complaints are reported. The best part – if you see a self-pay or out-of-network practitioner at the end of one year and the beginning of another – there are NO DEDUCTIBLES TO MEET! The fees posted are the fees posted, no extra costs.
So tell me,
If you are a health-conscious patient who is interested in they and their family getting premiere care without worrying about deductibles, co-payments and unexpected bills – then you owe it to yourself to select a provider who participates out-of-network and one that has self-pay options.
References:
FAIR Health. In-Network vs. Out-of-Network. Retrieved from: http://fairhealthconsumer.org/reimbursementseries.php?id=15
Munro, D. 2014. U.S. Health Care Ranked Dead Last Compared to 10 Other Countries. Retrieved from: http://www.forbes.com/sites/danmunro/2014/06/16/u-s-healthcare-ranked-dead-last-compared-to-10-other-countries/
Murray, C.J.L, et al. 2010. Ranking 37th – Measuring the Performance of the U.S. Health Care System. NEJM. 362: 98 – 99.
Original Article by: Dr. Erik Uuksulainen at truenorthchiropractic.com
