Can You Keep Your HMO Doctor?

[unic.consulting]

Don't bully, but "require" insurance companies..............oxymoron?
How can you require an insurance carrier to keep a doctor in network?

Same way they are required to keep medications on formulary. They can drop coverage on a med mid-year, but they have to continue to pay for that med for current patients until the plan year ends.

 

[VolAgent]

Same way they are required to keep medications on formulary. They can drop coverage on a med mid-year, but they have to continue to pay for that med for current patients until the plan year ends.

What if it was the doctor who decided to no longer take that network? Should the doctor be required to stay at that reimbursement rate, or is the carrier now required to eat the difference between what was the reimbursement rate and the new rate?

 

[unic.consulting]

What if it was the doctor who decided to no longer take that network? Should the doctor be required to stay at that reimbursement rate, or is the carrier now required to eat the difference between what was the reimbursement rate and the new rate?

Because the patient is not under contract with the doctor, the doctor should contact the patients with that plan, and give the patients the opportunity to find a new provider. If the patient decides to stay with the doctor, then they can possibly work out excess charges over the new reimbursement rate.

 

[VolAgent]

Because the patient is not under contract with the doctor, the doctor should contact the patients with that plan, and give the patients the opportunity to find a new provider. If the patient decides to stay with the doctor, then they can possibly work out excess charges over the new reimbursement rate.

So why can a doctor drop a network, but a network can't drop a doctor? Doesn't the doctor have a contract with the carrier/network?

 

[unic.consulting]

So why can a doctor drop a network, but a network can't drop a doctor? Doesn't the doctor have a contract with the carrier/network?

I didn't say the network couldn't drop the doctor. The issue is that the patient is in a contract with the insurance company. They can not switch insurance mid-year because the insurance company decided not to renew the contract with their doctor. There are a couple of other options that would work:

1) SEP for a client if their insurance drops their doctor.

2) Contracts with doctors must coincide with contracts with patients. (ie. Since ACA plans are from Jan 1 - Dec 31, contracts with doctors would also begin and end on these dates)

Do either of these sound like better options?

 

[taterpeeler]

Here is what I see in Texas:

1) BCBS HMO doctors in DFW are filling up fast and panel closed in some cases. Several calls from clients saying the doctors are not accepting new patients. Becoming somewhat a big problem however in my city by the Mexican border where Medicaid is big not having any calls from unhappy clients dur to provider problems. 1 client said she called 147 doctors all not taking new patients

2) Told H-1 doctors in San Antonio are full up and clients going to ER. Also HMO

3) PPO doctors don't know they are in network with BCBS and with that tried to turn the client away... after a discussion with me informing the provider failure to honor the PPo contract would result in termination of PPO membership across the state for the provider they decided to plan nice with the patients.

My own personal doctor said he did not take any ACA plans, period..... after explaining the situation to him(I don't have an ACA plan, im on group) he decided he better take the clients..

Bottom line, if you take the BCBS PPO in texas, their big one.. the old one.... you are in the obamacare plans that are PPO. Doctors refusing to take them will result in termination of their PPO contract....

Next, provider relations(training the providers) needs to be enhanced for 2015 as the providers are flat dumb.

Also, the provision relating to the 3 month grace period is the true root cause of this ordeal and that provision need to be eliminated for 2015.

And, without getting my head bashed in here there must be some form of uniformity related to charges like medicare.... some of you recall I stated years ago that this was not health care reform.... it was insurance reform.... it was never designed to control cost... you want to control cost control the source of the cost... provider charges.... and insurance policy is nothing more than a line of credit a consumer takes out......

Oh, another one... clients going to their PCP on an HMO getting their referral written out on a prescription slip to an out of network doctor and the carriers pushing back its out of network.... this is not in my view the clients fault, they are new formerly uninsured people, the referring doctor should do more research to refer to a par provider

 

[timsip]

No. That's not a fix. That's just bullying people out of business. But let's have doctors take the plans that they are contracted to take, make up-to-date lists of these doctors available, and require the insurance companies to continue to cover these doctors until the end of the plan year for current patients of these doctors.

Networks can change daily and doctors can drop carriers altogether. It could be because of reimbursements, volume of patients etc. There are only so many hours in a day and there is a set minimum revenue needed to stay in business. Requiring doctors to do certain things will only exasperate problems. Just like requiring insurers to do certain things has only exasperated problems. When will people learn that mandates do not solve problems, they make other problems worse?

Mandate doctors to remain in carrier networks and you can just plan on a longer wait time to get an appointment. This kills people especially in plans that require PCP referrals.

 

[unic.consulting]

Here is what I see in Texas:

1) BCBS HMO doctors in DFW are filling up fast and panel closed in some cases. Several calls from clients saying the doctors are not accepting new patients. Becoming somewhat a big problem however in my city by the Mexican border where Medicaid is big not having any calls from unhappy clients dur to provider problems. 1 client said she called 147 doctors all not taking new patients

2) Told H-1 doctors in San Antonio are full up and clients going to ER. Also HMO

This is the part I'm saying will take a few years to smooth out. Determining size of network/reimbursement rates/premiums with the increased volume of consumers is going to take a while.

3) PPO doctors don't know they are in network with BCBS and with that tried to turn the client away... after a discussion with me informing the provider failure to honor the PPo contract would result in termination of PPO membership across the state for the provider they decided to plan nice with the patients.

My own personal doctor said he did not take any ACA plans, period..... after explaining the situation to him(I don't have an ACA plan, im on group) he decided he better take the clients..

Bottom line, if you take the BCBS PPO in texas, their big one.. the old one.... you are in the obamacare plans that are PPO. Doctors refusing to take them will result in termination of their PPO contract....

And this is what I meant about doctors accepting the contracts they're signed up for. How many people got turned away because they didn't have you looking out for them?

Next, provider relations(training the providers) needs to be enhanced for 2015 as the providers are flat dumb.

Also, the provision relating to the 3 month grace period is the true root cause of this ordeal and that provision need to be eliminated for 2015.

So true.

And, without getting my head bashed in here there must be some form of uniformity related to charges like medicare.... some of you recall I stated years ago that this was not health care reform.... it was insurance reform.... it was never designed to control cost... you want to control cost control the source of the cost... provider charges.... and insurance policy is nothing more than a line of credit a consumer takes out......

I'm good with uniform reimbursement rates, but isn't that socialist?

Oh, another one... clients going to their PCP on an HMO getting their referral written out on a prescription slip to an out of network doctor and the carriers pushing back its out of network.... this is not in my view the clients fault, they are new formerly uninsured people, the referring doctor should do more research to refer to a par provider

Once again, this should be part of the provider (and office staff) training.

 

[AllenChicago]

more and more Doctors are simply limiting the amount of people they will see in a given network per month. They comply with the spirit of their agreement.

 

[unic.consulting]

Networks can change daily and doctors can drop carriers altogether. It could be because of reimbursements, volume of patients etc. There are only so many hours in a day and there is a set minimum revenue needed to stay in business. Requiring doctors to do certain things will only exasperate problems. Just like requiring insurers to do certain things has only exasperated problems. When will people learn that mandates do not solve problems, they make other problems worse?

Mandate doctors to remain in carrier networks and you can just plan on a longer wait time to get an appointment. This kills people especially in plans that require PCP referrals.

I understand that networks can change suddenly, but the person who gets shafted is the patient who picked a network because they wanted to keep their doctor, and then they're told no, but you're stuck paying us for 8 more months.

Locally, AARP Medicare Complete stopped covering the hospitals in Cambridge, but didn't let the patients or the private practices affiliated with those hospitals know. Now people are getting bills for hundreds or thousands of dollars because they were out of network.

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more and more Doctors are simply limiting the amount of people they will see in a given network per month. They comply with the spirit of their agreement.

And this I can't find fault with. After all, they are seeing patients, it just may take longer. This is a problem anyway (see Phoenix VA). The only solution to this is to encourage more doctors to do primary care work.