Quote:Actually, hospital payments rates are contracted for the majority of their patients. Medicare, Medicaid and Tricare are government programs, so you don't get to negotiate a rate, you simply take what they offer or don't participate. Commercial payers like Blue Cross, Aetna and United Healthcare negotiate individual contracts with physicians and facilities that pay on some percentage of the Medicare rate (good rates are 110 - 120% of Medicare, bad ones can be 80% or lower). Once the service is rendered the insurance company has the leverage because they can (and do) simply deny the claim and not pay it short of a judge forcing them to. They also deny claims for illegitimate reasons or say the service is the patient's responsibility and force the physician to rebill the claim costing labor time and a delay in cash flow or force the patient to spend time on the phone demanding they pay the claim. You've not seen corporate greed until you've seen how an insurance company works to hold on to their dollars!

 

The contracted rates also affect the hospital's fee schedule because the fee you send to the insurance company on the claim has to more than the contracted rate or they only pay the amount you bill. That constantly drives the fee schedule rates up because providers/hospitals are only allowed to have one fee schedule by law, therefore the fee has to be more than the highest contracted rate across your contracts.

 

All of these things factor in the administration of the health care and the need for this support is one of the largest influences on cost. In large provider groups the billing support staff requires at least 1 person for every 3 doctors. That's after the cost of the location, clerical staff, clinical staff, and supplies. But what choice do they have, either pay for staff to collect the money they're owed or go out of business. The same goes for hospitals but they gauge their staff need on number of beds and dollars in revenue. And none of this even covers government audits, insurance companies who take back the money they've paid by reducing or withholding payment on a different patient, the cost of IT in the new world of electronic medical records, or the cost of continuing education and compliance with ever-changing government requirements. One of my employees spends almost 2 months each year just reviewing and communicating the annual updates from CMS and ACHA to the Medicare and Medicaid programs. The bureaucracy of healthcare is something to behold and incredibly costly to the entire industry.

I understand the contract thing...That's why they have the separate fee schedule for in network and out of network providers...In network providers generally agree to accept whatever payment the insurance company pays and not bill for the difference between what was billed and what was paid...

 

I maintain that the healthcare system grossly overcharges in certain areas and that it is unfair and unethical, and should be illegal...I know a large portion of the billing goes to cover overhead and malpractice insurance, but the insurance companies don't need any help in finding an excuse to raise premiums...

 

I don't know how to solve the problem completely, but putting a realistic cap on the amount they can charge for dispensing medications at the ER, would be somewhere to start...

 

It was mentioned earlier that some people use the ER as a primary doctor facility and I know that's a fact...It's also a fact that some people use it as an excuse to get out of work...They don't want to work on a certain day, so they go to the ER and get a note saying they were seen at that facility and they have an excused absence. There is a lot of abuse of the health care system, and I think a major overhaul is what needs to happen...

 

It seems Canada's free health care system works pretty well, (although it's not completely free) but I doubt we could ever make a system like that work here because they jerk faces in Washington would find a way to screw it up and make it a pain in the rear

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