eagan@phoenix.UUCP (Marianne D. [Sarno] Eagan) (06/20/84)
Is it legal for doctors to vary their charges for a visit depending on the type of insurance you've got? I ask this because I called an acupuncturist and asked for his fees and the woman told me it depends on the type of insurance I have. That sounds fishy. What purpose does insurance if doctors just raise their prices if you've got it?
halle1@houxz.UUCP (J.HALLE) (06/22/84)
>Is it legal for doctors to vary their charges for a visit depending on >the type of insurance you've got? I ask this because I called an >acupuncturist and asked for his fees and the woman told me it depends >on the type of insurance I have. That sounds fishy. >What purpose does insurance if doctors just raise their prices if you've got it It is unethical, and probably illegal in many cases. If your insurance company should find out, they will consider his UCR (usual, customary, and reasonable) charge to be no more than his lowest charge, which means you may be stuck for the difference. It is a federal offense to do this for Medicare or Medicade patients. And if the doctor participates with Blue Shield, he is in violation of his contract and is subject to civil and criminal (fraud) charges. If you know of a doctor that does this, report him. (N.B. This is not the same as a doctor who charges everyone the same, but chooses to take a loss on someone who just cannot afford to pay. The latter is compassion, the former is insurance fraud.) If anyone in New Jersey knows of a specific instance of this insurance-based charging going on, please let me know. I will forward, in confidence, the information to the proper authorities. (Yes, I have BC/BS contacts.)
jwb@mcnc.UUCP (06/22/84)
One reason physicians have different fees depending on the source of payment is that Medicare/Medicaid payment is based on a *percentage* of the "usual, customary, reasonable fee", which varies by geographical area and medical specialty. The last I heard, around here the percentage was 80% of what Blue Cross/Blue Shield will pay. The physician has several alternatives. One is to accept the 80% from the Feds and attempt to collect the rest from the patient. Another is to just settle for 80%. Another is to not accept patients with this type of coverage. In addition to obvious problems with this scheme, in areas where Medicare pays a lot of claims, the private insurors are starting to adjust their allowable charges downward, saying the 80% level is becomming the prevailing fee. If this were continued, all fees would eventually converge to zero. Of course the objective of the Feds is to reduce the costs of their massively expensive health benefit programs without cutting off anyone's coverage. Their method, however, has produced massive confusion and incon- sistencies with respect to fees. The above method is gradually being scrapped, to be replaced with a flat fee, based on diagnosis, regardless of the actual costs to the health care provider. Presently this scheme (called DRG's, for Diagnosis Related Groupings, or something similar) applies only to hospitals, although everyone expects it to eventually apply to Physicians and to be adopted by the private insurors. It will open a new set of problems (for example for teaching hospitals, where costs are higher). Jack Buchanan Medicine and Biomedical Engineering Univ of North Carolina at Chapel Hill decvax!mcnc!jwb
halle1@houxz.UUCP (J.HALLE) (06/25/84)
I think you miss the point. Doctors cannot charge different fees for
different people based on their insurance coverage. Their fees must be
uniform. It is possible they might not collect the same amount from all
patients, but that is a different situation. The coinsurance that you
mentioned is not unique to Medica{re|id}, but is a feature of most Major
Medical plans.
Also, I do not follow your reasoning with respect to the companies reducing
their payments. If a doctor charges $100 for a procedure but only collects
$80 from the company, how could a company say his fee is only $80? The only
way I see is if the doctor failed to collect the $20 from those who were
obligated to pay, such as Medicare patients. If the doctor did indeed always
write this off, and especially if he only charged uninsured patients $80,
then his fee really is $80. In this case the company is correct to reduce
his payments, and should prosecute for insurance fraud. But if he tries to
collect $100 from everyone, then that is his fee.jwb@mcnc.UUCP (Jack W. Buchanan Jr.) (06/26/84)
It may be a semantic argument. I left out that doctors typically accept "assignment" of fees, particularly medicare. This means they will accept whatever medicare will pay and will not bill the patient an additional amount. There are built in (to the law) advantages for doing this, and the patient knows his insurance will cover his bill. By doing this the doctor is *de facto* saying he will accept the 80% as full payment. I submit this is fundamentally different from collecting whatever the insurance will pay and billing the patient for the rest.