Recently there has been a "loud" conversation involving out of network physicians, their patients and fees charged for these highly specialized services.
Some innuendos stated would have us believe that the out of network position a surgeon selects is immoral, unethical and this is the reason our medical system is in the state that it's in. Others believe that it is only fair and reasonable for medical professionals to choose their own track of patient and insurance relationship and not be obligated to engage in contractual relationships with anyone except the patient. Regardless of which side you are on, there is certainly a need for discussion about pricing on both sides.
There is an argument for supporting the in-network option as it reduces service costs and guarantees care to a certain degree. The in-network participation model also helps to maintain many practices that could not service their community if patients had to pay for all medical services directly. Providing service at a rate that supports the practice and community is good for both parties.
But there are certain programs that reimburse at rates which are not able to sustain a practice or promote a reimbursement rate that is considered acceptable to the practice or practitioners who service the patients. These rates are often non-negotiable, leaving few options.
These decisions often result in a debate as to the right or wrong of this position, but this is not the purpose of this article. The purpose of this article is to encourage physicians and practices to promote transparency in charges, proper fee schedule development and a patient advocacy position that aid patients through the very difficult revenue cycle that is part of the spine industry.
First, Transparency; what does this entail? It is imperative that practices disclose their non-contracted position from the initial discussion about payment, financial obligations and the patient's responsibilities. The practice is often aware of co-surgeons or assistant surgeons when surgery is considered as well as other costs involved, such as neuromonitoring, bracing and other additional services that the patient would not be aware of as a necessary component to the surgical success. Providing a list of those professionals involved and contact information is a way to promote disclosure and connection for the patient to reach out to other necessary contributors. This conversation should be supported by documentation which fully discloses the relationship and the expectation of the practice and patient involvement in working with insurance carriers in the reimbursement process. This information is vital to share with the patient so that he/she fully understands the agreed upon relationship before services are rendered.
Second, Fee Schedule Development; what is that process? There are several ways of developing a fee schedule. Options include the Relative Value Measurements, Medicare multipliers, organization such as FairHealth or publications such as Physician Fee Reference. Each practice should choose its methodology and document this process before implementing a fee schedule. Encouraging a discussion of the rates for services is recommended and presenting the patient with the charges for services for each procedure prevents sticker shock when receiving the statement of charges after the fact. You can discuss payment options, financial considerations based on hardships as well as case rate options if they apply.
Third and most critical, Patient Advocacy; who is assisting the patient through the reimbursement process? Many patients look to the practice to assist in managing the reimbursement process, and in the non-contracted business, the practice still has an obligation to perform this service. The challenges are significant for patients utilizing their out of network benefits, even though they have paid extra to use them. There are many cases where the benefits are not paid properly, requiring extensive levels of appeals or complaints to ensure that the benefits paid match the policy requirements. This requires a sophisticated staff and a patient willing to support the team. Balancing billing is not an option; although the patient may have some financial responsibility for deductible and coinsurance portions.
If practices wish to remain non-contracted and patients choose to utilize their out of network benefits, they should do so. Formatting a respective relationship with full disclosure and agreement is expected in any good business, even in the business of spine.