Well, the health insurance companies in New York have a new trick up their sleeves. Until very recently, insurance companies have been paying doctors who are “out-of-network” fees that are based on usual and customary rates (UCR). They usually pay 70 to 80% of these UCR and the patient is responsible for the difference between what the doctor charges and what the insurance company pays. The insurance companies used to determine UCR based on numbers established by a company they themselves set up. Attorney General Andrew Cuomo felt this was not appropriate or fair to the consumers because there was a conflict of interest and because the UCRs they set were lower than the actual UCRs as determined by analyzing true physician’s fees.
Under this old scheme patients had to pay more out of pocket. With the new methodology, insurance companies will have to pay more and consumers less. So the insurance companies decided to pull a switcheroo and stop basing reimbursements on UCR . They have been sending letters out to their subscribers telling them that they will now make payments based on medicare rates, the maximum pay-out being 140% of medicare fees. Medicare fees are woefully inadequate especially for reimbursement of surgical procedures. There is no way that physicians, especially surgeons can lower their fees to a fee anywhere close to 140% of medicare. Therefore, the consumer will now be out-of-pocket for far, far greater an amount then they had been with a UCR based fee.
If the insurance companies think that by pulling this switcheroo they will be able to force more doctors “in network” they are mistaken. Groups such as ours, will, in fact have to close the office doors if reimbursements are based on Medicare rates. We have far too great an over-head to be able to cover this over-head and still make an adequate living.
So, some physicians will move or retire and those left will have to try to maintain fees adequate to provide the revenue they require, leaving the patient to pay more out-of-pocket. The only way this miserable scenario can be avoided is for consumers to inform their insurance companies and their elected officials that this is unacceptable.
Both the insurance companies and the government want to change the way health-care is delivered, each for their own purposes and in the end, it seems, to the detriment of most patients.