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If you read Time magazine, you've likely already seen this story. If you haven't, pick up a copy or perhaps read this: Hospitals caught in middle as insurers and doctors battle over out-of-network charges .
It's quite clear to me what's going on. From a hospital's point of view, many, maybe most, doctors at hospitals are contract workers rather than hospital employees. As contracted employees, the doctors collect fees from the hospital, but aren't employed by the hospital.
This means that when one goes to a hospital for a procedure, the hospital can be "in network" with regard to one's insurance policy, the doctor who's performing the procedure -- the one with whom the patient has a relationship -- may also be "in network;" however, the other people who participate in providing for one's care may not at all be "in network." Since one or several doctors or other professionals who aid in delivering one's care in the hospital must be paid, they send a bill to one's insurer and the insurer sees they aren't "in network" and reimburses them at the lower "out of network" rate, leaving the patient to pay the remainder.
Now it's absolutely true that for scheduled procedures, one can conceivably take steps, or at least ask questions about who beside the doctor(s) with whom coordinated the procedure will participate in the process of performing the procedure, as well as performing pre and post procedure supporting activities. But how many of us are savvy enough about any given medical procedure to know just how many, who and what kind of professionals will participate in the procedure/care delivery? I submit that few folks who don't actually work in medicine have the faintest idea. Even knowing that sort of thing, is it at all reasonable to expect a patient to build his or her own team of professionals based around who is and is not in the insurer's network?
Looking at who cares whether all of the service providers are "in network," what does one find?
It's quite clear to me what's going on. From a hospital's point of view, many, maybe most, doctors at hospitals are contract workers rather than hospital employees. As contracted employees, the doctors collect fees from the hospital, but aren't employed by the hospital.
This means that when one goes to a hospital for a procedure, the hospital can be "in network" with regard to one's insurance policy, the doctor who's performing the procedure -- the one with whom the patient has a relationship -- may also be "in network;" however, the other people who participate in providing for one's care may not at all be "in network." Since one or several doctors or other professionals who aid in delivering one's care in the hospital must be paid, they send a bill to one's insurer and the insurer sees they aren't "in network" and reimburses them at the lower "out of network" rate, leaving the patient to pay the remainder.
Now it's absolutely true that for scheduled procedures, one can conceivably take steps, or at least ask questions about who beside the doctor(s) with whom coordinated the procedure will participate in the process of performing the procedure, as well as performing pre and post procedure supporting activities. But how many of us are savvy enough about any given medical procedure to know just how many, who and what kind of professionals will participate in the procedure/care delivery? I submit that few folks who don't actually work in medicine have the faintest idea. Even knowing that sort of thing, is it at all reasonable to expect a patient to build his or her own team of professionals based around who is and is not in the insurer's network?
Looking at who cares whether all of the service providers are "in network," what does one find?
- Patients care because it affects their out of pocket cost for care.
- Insurers care because it affects their reimbursement rates.
- Hospitals don't have an intrinsic reason to care because they want efficient operations and top quality care giving professionals, not professionals who are in this or that network.
- Doctors and other professionals don't care; they get paid a rate for performing a service.
