An associate of mine recently went to see a dentist. He was careful to read his insurance policy and go to its website to make certain that his dental work would be covered. Yes, the dentist he selected and the dental practice he visited were “in network”. However, once the procedure was complete, he was notified by his insurance company that the dentist performing the procedure was not “in network” and they rejected payment. My friend pointed out that the dentist in question was listed “in network” on the insurance company website, but the representative from the company corrected him as the dentist was in fact, “in network”, he was not “in network” at that particular dental practice, but was “in network” at another practice.
First rule of private insurance companies when receiving a claim: DENY.
If DENY fails, second rule is :DELAY.
My friend is now in the second phase of this and working with the insurance company to admit the DENY was bogus and to stop DELAY of payment.
How can this happen and why is it happening more and more?
Welcome: Private Equity!
As hospitals have outsourced emergency departments and other areas to reduce costs, private investors have bought up specialty physician practices, rolled them into powerful national corporations, and taken over hospital services. That time you went to “St. Elsewhere’ for that emergency room treatment of a nasty cut, or your colonoscopy, or follow up from a hip replacement, the physician or anesthesiologist, or physical therapist treating you may not even be an employee of “St. Elsewhere” (The hospital listed as “in network”), they may be an employee of “Uber Doctors” or “Amalgamated Anesthesiologist Supply” and …not in network, resulting in higher costs for you resulting in higher co-pays or perhaps, an outright denial of your claim. A recent report found that almost 65 percent of U.S. hospitals now have emergency rooms that are staffed by outside companies. In a recent survey forty percent of Americans reported receiving an unexpected medical bill; and 20 percent of those surveyed said it was due to out-of-network charges – or surprise billing.
This is simply more evidence to prove that markets fail when applied to health care and the remedy is not “More Markets” or “Failing Markets Helped by Government” AKA the ACA…..it’s time for the removal of markets and health care as right. Call it Medicare for All, call it socialized medicine, just once and for all get markets, and networks, out of the loop.