Who Accepts my Insurance Once Approved?

Do I have to find a doctor who accepts my insurance as I have to for other procedures, or will any surgeon take my insurance once I've been approved? I had a consultation 2 years ago and was approved by my insurance, but wasn't comfortable with the surgeon. Now I'm trying to find a new doctor but don't know if I have to check that they accept my insurance beforehand

Doctor Answers 2

Health insurance

No surgeon "has to take" your insurance, and many will not.  If you want to stay "in network" the doctors on the insurance panel have agreed to accept payment at a lower rate than they may have if they were not "in network."

New York Plastic Surgeon
4.1 out of 5 stars 29 reviews

Health insurance

Boy have you opened a can of worms.

Historically speaking, 50+ years ago there was no such thing as health insurance. Patients simply paid their physicians. With increasing technology, liability & other costs the average individual could no longer afford health care & the health insurance industry arose to fulfill a need. There were separate policies for hospital care & others for health care professionals. However, patients paid their bills & were reimbursed by their insurance company. This arrangement changed in the 1950s through 1960s when insurance premiums rose & insurance companies paid the bills directly. Copays & deductibles were introduced to prevent
overutilization of services by patients. Most policies were independently purchased by subscribers.

In the 1970s the introduction of better computers allowed the codification of services provided by doctors & hospitals & the diagnoses of patients. Then services supplied by different health care providers could be compared including their fees. Much of this was government initiated to control Medicare and Medicaid budgets. The government set out to assign work units to different codes & say how much it would pay
for different codes. The private insurance companies in general were paying 2 to 3 times the amount of the government's corresponding fees. The amount paid per code was based on the usual, customary & reasonable amount in the area where services were delivered i.e. what the average doctor was charging. Things started out that way but then were warped by the insurance companies who had the charge data but would not release it. The doctors could not discuss those charges among themselves as that would be an FTC violation. It turns out that around 2009 this manipulation was discovered and prosecuted by then New York DA Cuomo. The companies said they were using a third party to calculate those fees but it turns out they owned the third party and manipulated the numbers to their advantage. This resulting class action lawsuit resulted in a multibillion dollar settlement with 100s and 1000s payments to patients and doctors, millions or billions to lawyers and then business as usual by the insurance companies.

While the government based its Medicare and Medicaid payments on having a fixed amount of money to spend on healthcare & controlling this as a percentage of inflation & GNP the insurance companies thought differently. Since the 1980s the government decreased it's fee schedule for procedures dramatically. The
insurance companies followed suit dropping from 2 to 3 times the government fee to 1.5 to 2 times. They have continued this to the level of 1.1 to 1.2 times the government fee. In some cases they are offering
contracts of 0.6 to 0.7 times the government. Coupled with greater than 70% increases in premiums, corrected for inflation in the last 20 to 30 years they are making a bundle. They are picking fee schedules which they call allowed amounts that maximize their profits & pegging them to the government rate. This is particularly troublesome since the government rate relates to federal budgets & has nothing to do with how much it costs to deliver those services no matter what they say in government speak.

Since the insurance companies now had very large portions of the patient pool under their control they began to influence healthcare in the 1970s to maximize their profits by controlling the delivery & cost of care. This started with contracts with individual doctors at reduced rates in returns for promises of higher volumes of patients by accepting the negotiated rate. This worked for a short time for the initial signing doctors but as more signed on volumes reduced and it turns out so did payments and the doctors had no negotiating leverage.

In order to continue to increase profits health insurance companies then began to download their risk onto physicians they contracted with in the form of capitation. Physicians or groups of physicians (Independent
Physician Associations-IPAs)are paid a specific amount per patient per month to take care of whatever may arise in those assigned patients. Thus, they were no longer an insurance company - a seller of contracts
guaranteeing payment for a health related loss. Instead they brokered money. The IPAs in turn low balled their bids in order to beat other IPAs to get insurance contracts. They had insufficient money to pay for
claims especially as the end of fiscal years. Like an overcharging individual trying to pick which credit card to pay on a given month IPAs prioritized their creditors. In those days I would do emergency room work and the IPA would be half the bill a year later. Additionally, the IPA would not allow the patient to see me after emergency room treatment because their capitated physicians were cheaper. One IPA still has not
paid a $300 bill after all these years despite making me jump through the hoops of obtaining IRS forms, sending claims to different office addresses, etc.

Over the years it has become increasingly fiscally impossible to accept these negotiated rate contracts so you see doctors dropping out of participation. If the doctor has a contract with the insurance company the rates are fixed. If you go to a non-participating doctor there is no negotiated rate the doctor charges whatever he/she charges. The insurance company does not want you to go to that doctor so they pay even less than they would to a participating contracted doctor. Therefore you are paying the difference between a discounted negotiated rate and the doctor's rate not the difference between the negotiated rate and the doctor's rate. It is a free country is some aspects anyway so you can go to whichever doctor you want but expect to pay more for a non-participating doctor. Also expect to feel inceasingly uncomfortable with whatever doctors participate with/accept your health insurance as inflation raises the cost of everything but insurance company payouts do not keep up with those increases.

The latest trend in healthcare is for doctors to become employees so they are paid hourly or receive fixed yearly salaries. The government has gotten on this bandwagon since Mr. Obama became president. It has just reached the point that the doctor is paid so little per office visit or surgery that his/her independent practice is no longer financially viable. The problem here is the doctor works for someone or something whose control over that doctor can be detrimental and/or costly to patient care.

If everyone paid their credit card & utility bills the way health insurance companies pay their bills the entire system would crack.

Aaron Stone, MD
Los Angeles Plastic Surgeon
5.0 out of 5 stars 2 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.