The current industry model for reimbursing out-of-network care is - TopicsExpress

The current industry model for reimbursing out-of-network care is fraudulent. The industry uses a conflict-laden database riddled with errors at the expense of the consumer. The database is neither independent nor fair. This leads to chronically flawed decisions. Given the heavy burden of health care costs that working families must bear when insurers fail to pay what they owe, the out-of-network system must be fixed. We conclude that the consumer reimbursement system is code blue and certain reforms are necessary. First, the “usual and customary” or market rates for reimbursement of health care charges should be determined by an independent third party free of conflicts of interest, using a fair, objective, and reliable database. We reject the notion that an insurer can credibly decide the fair market rate of health care charges, given the insurer’s obligation to reimburse the consumer a portion of that rate. The insurer has an untenable conflict of interest — one that must be removed. Second, before consumers choose an out-of-network doctor, they should know what it will cost them. It is one of the most important consumer purchases, yet pricing information is practically nonexistent in the out-of-network setting. The lack of transparency in the health care industry is striking. Consumers need more information about how they will be reimbursed and they need it earlier in the decision-making process. A website tool available to the public, showing common health care services and the market rates in relevant geographic areas, would be a giant leap forward in the battle for transparency in health care. Knowing the price helps the consumer shop, and transparency helps the market and the entire industry function efficiently. All of these concerns were taken into account and were settled for the entire nation in 2009. The PPACA was passed in 2010 to reflect these protections for consumers as well as many other changes that were needed to protect consumers and create an affordable transparent means for patients to get the health care they need and PAY for! However, the insurance companies are committing fraud again and these issues need to be brought to the attention of elected officials both state and federal. More to come!

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