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Unpleasant Surprises for Pennsylvania Physicians


By Gus Geraci, MD

A hot topic right now at the Pennsylvania Medical Society is unpleasant surprises.

The first unpleasant surprise was to physicians from Highmark, announcing a 4.5 percent cut in reimbursement for Obamacare insurance products.

Imagine your plumber saying he was going to charge you more, because business wasn’t as good as he expected in his plumbing business. And because you signed a contract to do business with him, you would just have to accept that.

Highmark says it is losing money because of unexpected expenses in the market from Obamacare policies. As a result, they, unilaterally of course, cut reimbursement to physicians for their marketplace policies because they need to cut their costs somewhere.

This despite increases in their insurance plans for 2016, which were into the 20 percent range.

My personal plan went up more than that, and changed how the deductible was calculated, so I am now paying for all my meds from the deductible, which only when exhausted will start to pay for my health-sustaining medications. Yes, that makes a lot of sense.

PAMED has written letters to Highmark and the Pennsylvania Insurance Department asking for a reverse of the cuts. Highmark uses a tying arrangement in its contracts, which means if you sign with Highmark, you have to accept all their plans and whatever changes they make in those plans, unless you want to stop accepting all their plans.

That is hardly an option for most physicians, especially where Highmark is a dominant payer. So take the reduction, or drop all Highmark plans. Not really is that a choice.

We’ll have to see what happens. If you will be adversely affected, let us know by commenting at the bottom of this page.

The second surprise issue is the issue of surprise billing. Imagine you have a car accident, and your car insurance normally pays for repairs. Then imagine you get a separate bill from a “transmission specialist” who doesn’t take your car insurance.

Suddenly, you’re on the hook for thousands of dollars when you thought it was all covered. But, no, the transmission specialist does not take your car insurance, and the insurer won’t pay them, and you never knew till after the work was done.

Well, that happens to patients too.

When you’re called to assist in surgery, or administer anesthesia, or do a procedure emergently, do you always ask what the patient’s insurance is, to be sure you accept that insurance? And if you don’t, do you refuse to provide care, when it might mean delays and unnecessary risk?

Maybe, but I bet most of the time, no.

But if you do the work and you don’t participate in the patient’s insurance, you bill them, and they get an unpleasant surprise.

The Wolf Administration sent a draft proposal that could be turned into legislation to address that issue, and needless to say, there is lots of discussion about how to handle that.

Mandating that physicians accept the insurer’s payment negates the whole purpose of not participating with certain insurers because their rates or terms are unreasonable. Allowing physicians to charge their “customary” rates and forcing the insurer to accept that may mean abuses like this case, where a patient received a $117,000 bill from an assistant surgeon who was out of network.

This is admittedly a complex topic. Not only does it include navigating the rights of physicians to have reasonable fees, it also involves contracting with insurers that pay fairly and have reasonable agreements, and the rights of the patient to be protected from unexpected bills.

I’m not sure there is an answer that will make everyone happy, but if you think you know one let us know.

Meanwhile, add it to the list of things that the Pennsylvania Medical Society is working to address on your behalf.

PAMED sent a letter to the Pennsylvania Insurance  Department that called surprise billing a “side-effect of inadequate networks and unfair contracting and potential patient misunderstanding about the insurance products they have purchased.” In addition, the Society’s new payer advocacy task force is further examining the issue.​

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