"New Obamacare Loophole Shows Failure of For-Profit Health System: Critics"..

[truth2power]

I'm not sure if everything about the ACA should be in that thread that's pinned. If so, I'll delete this and put it there.

Link: http://www.commondreams.org/headline/2014/05/16-4

Announced on May 2, a new loophole in ACA would open the door to "reference pricing", allowing insurance companies to set their own prices for some medical procedures. The patient would have to pay out-of-pocket for the balance.

Another reason we need universal health CARE.

Many worry that reference pricing will force patients to bear the burden of a costly and difficult-to-navigate medical system.

"We don't need reference pricing—we need "right pricing" under a single-payer program," Don McCanne, M.D., senior health policy fellow at Physicians for a National Health Program told Common Dreams. "This is merely another way in which insurance companies are going to chisel down payment for care, shifting a greater share of the cost onto patients."

Comments?

[upaloopa]

1. I don't understand why an insurance company

Would price a medical procedure. The insurance company is the payer not the provider. The provider sets the cost then bills the insurance company. The patient does not pay an insurance company for a procedure.
This smells fishy to me.
Insurance companies already determine what they will reimburse a provider for a procedure. That is nothing new.

[djean111]

2. Yes, right now a patient pays the deductible (or nothing) and the provider and the insurer work out

how much will be charged to/paid for by the insurer. Patient is not involved.
Looks like now the patient will pay a deductible and then any difference between what the insurer will pay and what is actually charged. And since a lot of policies require that one uses providers on their pre-approved list, not that easy to shop around for the last expensive.

This is what happens when our government lets the insurers and Pharma write the bills.
I see more medical bankruptcies in the future.

[truth2power]

5. It sounds like you have a sense of what's really involved here...

I don't post much about the ACA because any dissent from the party line just brings out the Harpies bellowing about how you must "hate" Obama.

Aside from that stance being typical of an earlier (adolescent) stage of development, it's a waste of time trying to point out the realities of where this is all going.

I've saved some articles written about a year ago, detailing the flaws in this system, written, as you said, by the insurance companies. One of which you've touched on, i.e., not enough providers on the pre-approved list.

I think the proof of the pudding will be when a large number of providers begin to submit insurance claims for various medical procedures. Then we shall see the extent to what insurance companies are able to weasel out of. JMHO.

[Doctor_J]

8. The insurance companies WROTE the ACA

These are not flaws to them - they're features.

[truth2power]

3. I think there's some confusion here...

and maybe it's the way the article is written.

An insurance company doesn't PRICE a procedure, as such, but as you said in your last sentence, they certainly do decide how much they will pay for a particular procedure. If the doctor or hospital has charged above that amount then the patient is on the hook for the balance.

I think the confusion is in the phrase, "which allows insurance companies to set a price for medical procedures." Yes, set a dollar amount for what they will pay. See above.

I know it's unseemly to speak ill of the ACA, but I've come to the conclusion that it was, indeed, written by , and for, the insurance companies. And they will profit, handsomely, I might add, to the detriment of the patients' needs.

[upaloopa]

4. I was a controller of a medical clinc

Each year insurance companies would contract with us. They had a reimbursement rate for every procedure. As does Medicare and Medicaid.
If we agreed with the reimbursement rate we would enter a contract. Once done the reimbursement amout is all we received for a procedure. We did not charge patient anything except a deductable.
If the reimbursement rate was too low then we would not contract with the insurance co. In that case we took the reimbursement paid and charged the patient the difference.
This is exactly like in the OP. It is not new and it is not the ACA doing this!

[truth2power]

6. It will apply to the ACA...

And I don't understand this statement: "If the reimbursement rate was too low then we would not contract with the insurance co. In that case we took the reimbursement paid and charged the patient the difference."

If the reimbursement rate was too low you took the money anyway. From the insurance company, I assume. Thus you contracted with the insurance company. Then you charged the patient the difference. So you got all your money no matter what.

Where are the rules that say what percentage of a medical procedure an insurance company can consider reasonable to pay? What if an insurance company decides that what they're willing to pay for a $4,000 procedure is only $500? So the patient is stuck with a $3500 out of pocket.

Again, the ACA was written by the insurance companies. Just as in a casino, the house doesn't lose, ultimately, even though some individuals make out quite well. The profit-driven insurance companies, likewise.

But this will all come out in the wash, notwithstanding any disagreements on this board. Wait until a lot of claims start coming in and the stories get posted somewhere.

[upaloopa]

9. We billed a patient's insurance company

and took the reimbursed amount but we did not contract with them. We did not have to accept the patient's insurance if we thought it's reimbursement was too low we did not contract with the ins co
Don't tell me what my job was
Sorry reality doesn't reflect your paradigm

[truth2power]

11. As I said, if the reimbursement rate was too low, yu took the money anyway...

It just seemed to me that if you take money from someone for a service provided, there's an implied contract in there somewhere.

But never mind. You seemed to gloss over the crux of the issue, which is that the patient is going to get stuck with something over the $6000 deductible which many already have to pay.

The ACA was written by insurance companies, and they're going to win. Every time.


Last night I was listening to an interview with Chris Hedges. He said, "Any legitimate debate about health care should begin with the factual understanding that the for-profit healthcare industry is the problem. It must be destroyed; then we can talk about a system."

[IronLionZion]

10. Medical pricing makes absolutely no sense at all

its a struggle between big hospital corps and big insurance over how much to charge and how much they are willing to pay for it. That's why prices can vary quite dramatically across different providers even in the same city. Smaller insurers or providers don't really have much bargaining power.

Making pricing more transparent is an attempt to bring more fairness to pricing. Patients might like to know how much a procedure will cost before getting shocked by an artificially inflated bill, that needs to be negotiated down to something more reasonable.

I support single payer as much as anyone, but the big payers like medicare/medicaid and insurers are really the only check on health care costs we have. An individual patient doesn't stand a chance on his/her own.

[Doctor_J]

7. I really thought that the the insurance companies would play fair once Heritage Care passed

This is a "loophole"? The whole Act is a loophole.