Networks participation is extraordinarily plastic. Providers can leave networks at will, and entry can be anywhere from signing a new contract to being invited in to being wined, dined and sixty-nined until the provider agrees to participate.
In the past year for Mayhew Insurance, providers have left our primary commercial (non-Exchange) network for the following reasons:
- Kicked a provider out after a federal indictment for prescription drug fraud (rare)
- Decided to move to Florida, South Carolina or Arizona to work on the golf game (common)
- Died (uncommon)
- Retired (common)
- Declined to renew as there were not enough Mayhew Commercial members in the region but stayed on as a Mayhew Medicare provider (uncommon)
- Withdrew as Mayhew Insurance signed three more docs within 2 miles of provider’s office location (uncommon)
- Got bought out by an integrated provider-payer organization that does not take Mayhew Commercial (common)
- Meth lab or gas leak explosion two suites over made the facility unusable (happened more than once)
- Removed from the network due to licenses expiring in Mayhew area of service (common)
- Removed from the network due to multiple malpractice claims (uncommon)
- Removed from the network as we no longer selling insurance in those counties (uncommon)
- Why the hell not (common)
- We have not paid a claim to this doc in over three years — why continue the relationship?
- Mayhew Insurance won’t increase reimbursement rates by 50% and Major Competitor Company will pay 30% better than Mayhew.
When evaluating a network, it is quite possible for a doc to be in network today and out of network next week. Sometimes those are mutual decisions, sometimes they are insurance company decisions, some times they are regulatory decisions but most of the network churn in an established network is from provider decisions.
daveNYC
So… does that count as common or uncommon?
Villago Delenda Est
“Just because” seems to be missing from your laundry list, although “Why the hell not” comes pretty close to that.
Richard, also, may I state for the record, your assimilation in to the BJ Borg is a delight (using or alluding to song lyrics in your post titles, that is…)
Richard Mayhew
@daveNYC: uncommon
cleek
* Because Obama made me (the most common evah!)
MomSense
I just paid my first premium!! I am beyond thrilled. After the payment went through the person on the phone congratulated me and if I could have, I would have given him a kiss through the telephone.
I just can’t believe we have had to endure so much drama over something so basic. I bet there are a lot of people who are now thinking WTF was all the fuss about?!
rikyrah
People: ‘I’ve Got 3 Opinionated, Strong, Tall Women’
Sitting down for their annual interview with PEOPLE, President and Mrs. Obama reflect on the year’s difficulties, both in the political arena and the smaller challenges he encounters at home.
“I’ve got three opinionated, strong, tall women,” says President Obama. “If they get together, they can have fun about my ears or being too loud, or how I dress.”
…. The Obamas reveal that daughters Sasha, 12, and Malia, 15, weigh in on Mom’s fashion choices and have tutored Dad in using Instagram and Vine. And, like any kids, they are occasionally embarrassed by their parents.
“Malia had friends over, and there was a question about whether she was going to even introduce them [to her dad], because sometimes he gets a little formal, asking them about school and interests,” the First Lady tells PEOPLE. “She says, ‘I don’t know if my friends can handle that.’” Then she turns to her husband and says, “But she said that you actually did quite well.”
“I acquitted myself well,” notes the President. “I did not embarrass her.”
http://www.people.com/people/article/0,,20767223,00.html
MomSense
@rikyrah:
I can’t wait to read that article.
rikyrah
Washington Post: California is averaging 15,000 Obamacare enrollments each day
State health exchanges are reporting a surge in enrollment — and consumer interest — as they near a late December deadline to purchase insurance coverage.
If November had an Obamacare surge, consider this the December deluge. California averaged 15,000 daily enrollments early last week, about double the sign-ups the state had in early December. New York is now seeing about 4,500 residents choosing plans each day and, in Connecticut, the number is hovering around 1,400.
With consumer interest seeming to spike, these states and others are increasing call center staffing by half.
“We continue to see a tremendous increase in enrollment,” says Lisa Sbrana, counsel to New York State of Health. “We’re averaging between 1,200 and 1,500 calls per hour and have seen a 34 percent increase in enrollment from last week to this week.”
http://www.washingtonpost.com/blogs/wonkblog/wp/2013/12/18/california-is-averaging-15000-obamacare-enrollments-each-day/
rikyrah
The GOP Repeal Trap
By Greg Sargent
December 18 at 3:39 pm
The Journal Gazette of Fort Wayne, Indiana, reports on a fascinating exchange between GOP Rep. Marlin Stutzman and a local meat market owner, Lee Albright, who likes the Affordable Care Act and quizzed the Congressman about the real world implications of the GOP repeal stance:
The Republican seems to be implicitly conceding not only that the GOP repeal stance is politically problematic, but also that the Republican position constitutes taking health coverage away from people.
Stutzman doesn’t appear to be vulnerable, but the episode nicely illustrates the broader problems with the repeal stance, i.e., that the de facto GOP position right now is to return to the old system, and that this isn’t a palatable alternative, even though Obamacare is unpopular.
http://www.washingtonpost.com/blogs/plum-line/wp/2013/12/18/the-gop-repeal-trap/
Belafon
@rikyrah:
I do that with my kids’ friends. What am I going to ask them about, who they’ve got a crush on or what they thought about Megan’s dissing of Savannah last week?
rikyrah
Matt Roush’s Top 10 of 2013
Dec 18, 2013 07:01 AM ET
by Matt Roush
1. Breaking Bad
What a way to go out — with a bang, on a tragic yet triumphant high, at the peak of popularity and notoriety. What could be more satisfying than that? There wasn’t a wasted moment or unexplored opportunity for suspenseful conflict in the intense last chapters of AMC’s masterful thriller, charting Walter White’s ultimate descent into criminal infamy. Bryan Cranston brilliantly captured the character’s mood swings, from wounded pride to murderous rage to sorrow over the family he lost due to his dark machinations. No maddening ambiguities in this grand finale.
2. The Good Wife
Forget “good.” In its fifth season, CBS’s (and network TV’s) classiest and most entertaining drama has returned to greatness with an audacious act of reinvention, turning former partners — and lovers — into mortal enemies following Alicia’s (Julianna Margulies) split to start her own law firm. Everything is now beyond personal in this dangerously exciting, unpredictable new scenario. Even better, the show has lost none of its smart sex appeal and continues to tell some of the most gripping legal stories anywhere. Bravo.
3. Broadchurch
America’s shattering mystery, set in a British seaside village teeming with secrets, introduces an instant-classic detective partnership: Olivia Colman and David Tennant as Ellie Miller, a lifelong resident of provincial Broadchurch, and Alec Hardy, a brusque Scottish interloper. As a witch-hunt mentality envelops the town after a young boy’s murder, suspicion and, especially, emotions run high. Broadchurch elevates the whodunit with profound sensitivity and has spawned a U.S. remake on Fox.
4. Masters of Sex
From Showtime, the year’s most provocative and stimulating new series uncannily blends the kinky and the clinical as it dramatizes the pioneering research of William Masters and Virginia Johnson, portrayed by Michael Sheen and Lizzy Caplan, both of whom are superb at mining the passion that comes with ambition. Amid the repressive 1950s, when few dared speak of such things, their meticulous and graphic study of the biology of sexual behavior breaks down cultural taboos while invariably drawing them into uncharted territory: the unknowable mysteries of love and attraction, and the paradoxes of the human heart.
5. Orange Is the New Black
How ironic that this addictive dark comedy set in a women’s prison feels so creatively liberating. Netflix’s best series in a breakthrough year rewards the binge-watching experience as it builds from naive inmate Piper Kerman’s memoir into a character-driven study of the wonderfully diverse people, each with a surprising backstory, she encounters during her disorienting incarceration.
http://www.tvguide.com/News/Matt-Roushs-10-1074816.aspx
Baud
@rikyrah:
He just can’t stop spying on people. ;-)
rikyrah
NBC: Patients pour on to successful state insurance exchanges
People are flocking to the more successful state health insurance exchanges in the final days before a late-December deadline, exchange directors said Wednesday.
So many people are calling in for help that states have had to beef up call center staffing, and insurers have agreed to let deadlines slide a bit so that as many people as possible can get coverage starting Jan 1.
In just five states – California, Connecticut, Kentucky, New York and Washington – more than 436,000 people are signed up for health insurance – more than in the 36 states covered by the federal exchange. But the directors of the five exchanges say what’s happening in their states reflects much of what is going on nationwide – people want health insurance being offered by the Affordable Care Act.
“We are seeing huge interest,” said Peter Lee, executive director of Covered California. “In the first week of December we had 50,000 pick a plan in Covered California. That’s an average of 7,000 a day.” Last week, Lee says, 15,000 people a day were signing up for insurance in California. New York is enrolling 4,500 people a day, Lisa Sbrana, counsel to the New York exchange, said.
http://www.nbcnews.com/health/patients-pour-successful-state-insurance-exchanges-2D11770338
Amir Khalid
Off-topic, but I have a medical costs question: I’m having an electrocardiogram Friday at the University of Malaya Medical Centre, ahead of a doctor’s appointment. It will cost 120 ringgit (about US$37). How much is an EKG in the US?
rikyrah
teve Benen: Dems’ sweep in Virginia now complete
The recount in Virginia’s remarkably close race for state attorney general wasn’t quite complete, but the writing was on the wall. Rather than push the contest into the hands of state lawmakers or into the courts, the Republican decided to bow out.
…. Democrats have won all three statewide races in Virginia for the first time since 1989. What’s more, this is the first time in four decades that Virginia will have a Democratic governor, Democratic lieutenant governor, Democratic attorney general, and two Democratic U.S. senators.
…. So, for all the talk about Obama’s “year from hell,” his party just swept all of the statewide contests in this key swing state. Republicans, strategists, and pundits assuming GOP successes in 2014 should probably take note.
http://www.msnbc.com/rachel-maddow-show/dems-sweep-virginia-now-complete
Baud
@Amir Khalid:
It would cost $fuckyou.00.
Elizabelle
@Amir Khalid:
The cost of an EKG is not knowable. Even if you ask your doctor. They brush you off with “it all depends on your insurance company/coverage.”
ETA: I would suppose that if you offered to pay for it entirely out of pocket, you would get a quote many times that of what an insured person would pay. Who knows how much the quote relates to the actual cost of providing the service?
It’s America, Amir.
rikyrah
Morning Plum: Despite O’care rollout, Americans want to expand safety net
By Greg Sargent
December 19 at 9:02 am
It’s been widely suggested that Obamacare’s rollout failures threaten to bring down the entire liberal project, by getting Americans to turn on the idea that activist government should — or can — solve major problems facing the country and effectively protect people from financial and medical harm.
Anything is possible over the long haul, of course, but a new poll suggests this just isn’t happening. It finds that despite deep skepticism of the law, majorities still support the idea that the federal government has a responsibility to expand health coverage to those who lack it.
Today’s New York Times/CBS News poll will get attention because it finds that a majority of the uninsured disapprove of Obamacare. That is potentially a big deal, since it could mean fewer will sign up for the exchanges over time. Overall, large numbers disapprove of Obama on the issue and say the law faces major problems and won’t make things better. But here’s what the poll also finds:
* A majority of Americans says “providing access to affordable health care coverage for all Americans is the responsibility of the federal government,” by 54-43.
* A majority says that “when individuals don’t have health insurance,” it “hurts the country,” by 70-22.
* A majority says “providing health care coverage for the poor is the responsibility of the federal government,” by 53-41.
http://www.washingtonpost.com/blogs/plum-line/wp/2013/12/19/morning-plum-despite-ocare-rollout-americans-want-to-expand-safety-net/
Belafon
@rikyrah: This is what is going to cause the business Republicans to have a lot of heartburn over the next few years. Republicans should have won Virginia, but the wingnut candidates that ran were too much for the state.
I hope this occurs again next year in other states. Oh, how I wish something like that would happen in Texas.
Baud
@Baud:
@Amir Khalid:
You know I’m kidding, of course. Hope your EKG is just routine.
Amir Khalid
@Baud:
No offence taken. I took you to mean pretty much what Elizabelle said.
burnspbesq
@Amir Khalid:
In our system, it would depend on whether you have insurance, and if you have insurance, what your deductible and copayment are.
$37 out of pocket would be a good outcome.
http://health.costhelper.com/ecg.html
Certified Mutant Enemy
@Amir Khalid:
A bit more than $37. ;)
Amir Khalid
@burnspbesq:
Good Lord, as much as three freaking grand? What do these hospitals do, buy a new machine for every EKG they run?
sparrow
@rikyrah: Interesting posts. Cole should make you a frontpager :)
Gene108
@Amir Khalid:
Hard to say in the US. Medical pricing is murky, I.e the same procedure will be charged/paid at different rates depending on who is paying – Medicare, you paying cash, or private insurance.
Anyway, if this helps compare prices a visit to a doctor because you are sick (cold, flu, etc) can run about $125 USD.
Elizabelle
@Belafon:
Agreed, Virginia was a winnable state for the Republicans, had they put up more moderate-seeming candidates.
The GOP will not win in Virginia with batshit insane candidates. Which is what the GOP “activists” convention delivered. Obenshain was the most moderate-seeming of the three, and he came extremely close to winning AG.
I thought the local (and MSNBC) reporting was extremely dishonest in not coming out with that.
Lots of mumbojumbo over “demographic change” and “the Obama coalition.”
On Newschannel 8, the Politico woman did inform that a candidate who won in Northern Virginia would not win downstate.
Now why is that? Crickets!
Glidwrith
@Amir Khalid: More than $600 after the insurance got through with me.
ETA: this was before the reforms went into effect.
Elizabelle
@Amir Khalid:
You might do better costwise if you could convince them you’re a husky or a German Shepherd.
rikyrah
Lupita Nyong’o in “12 Years a Slave”
December 17, 2013, 6:25 AM|Golden Globe and Screen Actors Guild nominee Lupita Nyong’o got the part of Patsey in the critically-acclaimed film “12 Years a Slave” just after graduating from the Masters Program at Yale Drama School. Nyong’o joins the “CBS This Morning” co-hosts to discuss the emotional film and her inspiration.
http://www.cbsnews.com/videos/lupita-nyongo-in-12-years-a-slave/
Amir Khalid
What you all have just told me about pricing for medical services in America is rather frightening. It seems to me that having a menu with fixed prices, the way it’s done here, is the obvious and much better way to do it — especially for a routine procedure done by a technician, like an EKG.
Gene108
@rikyrah:
It is like the politically correct conservative maxim with regards to gays, ” hate the sin, love the sinner.”
Love the benefits of the law, but hate the actual law as a whole.
Also, too insuring the poor is a great idea, as long as I do not have to pay for it.
If only unicorn farts were real hard currency. We could pay for so many social justice issues life would be great.
maximiliano furtive, formerly known as dr. bloor
Your post focuses entirely on why providers leave. Why do insurance companies toss licensed, willing providers without cause?
Gene108
@Elizabelle:
What worries me about the 2016 Presidential election is the GOP base may figure out that toning it down will be a winning strategy.
Amir Khalid
@Gene108:
Seeing a private doctor is fifty ringgit in Malaysia, exclusive of any medication prescribed. (RM3.20 = S$1.) Unless you have a job, in which case all outpatient care and meds for you and eligible immediate family (spouse, kids) must be paid for by your employer.
japa21
Richard, pretty comprehensive list. I have been sitting here thinking of other reasons and haven’t come up with one yet.
It is important to note that some of these occurences happen, i.e. the buyout of a practice where the new owner does not take Mayhew insurance and the insurance company is not always notified in a timely manner.
The provider’s name remains in the insurance company directory and people will therefore assume they are still innetwork with that provider.
That is the reason why insurance companies advise patients to confirm network participation with the provider. Unfortunately, many patients don’t and the providers will not inform them they are no longer in network, so bills are paid as out of network and the patient owes more than they expected to. And when that happens, the patuient goes after the insurance company and the provider usually says, tough luck.
Richard Mayhew
@maximiliano furtive, formerly known as dr. bloor:
I listed a couple of insurance company reasons:
•Kicked a provider out after a federal indictment for prescription drug fraud (rare)
•Removed from the network due to licenses expiring in Mayhew area of service (common)
•Removed from the network due to multiple malpractice claims (uncommon)
•Removed from the network as we no longer selling insurance in those counties (uncommon)
•We have not paid a claim to this doc in over three years — why continue the relationship?
Mike in NC
@Amir Khalid: Rule of thumb in America has always been not to get sick in the first place; otherwise you might end up destitute.
piratedan
@Amir Khalid: based on a bill I just received from my local hospital for my weight loss surgery, mine was 495.00. Naturally, they told me that it wasn’t a bill and it had to be submitted to insurance before I will know how much I really have to pay (which may be nothing since I’m pretty sure I’ve met my deductable already)
donnah
@MomSense: Well, my husband is Day Five of applying for the new insurance, so I hope to share your exuberance soon. He had tried to join a plan that would include our 20 year old student son, but it added too much to the monthly payment, so he tried to take him off the plan, and they had to cancel the entire application, then he spoke to someone online last night and they told him our son could be included at a lower rate, but we still can’t change it because they already tried to cancel our original application. He has to start over from scratch.
I can understand how people have gotten frustrated. We’re big supporters of the ACA, but this is a pain in the ass.
JustRuss
You forgot to add “and Obama” /wingnut
MomSense
@donnah:
Sorry to hear that you have had to deal with those problems. Stick with it! The navigators are very helpful and I’m sure they will sort it out soon.
Bill Arnold
@Gene108:
That worries me too. The most unsettling aspect of the recent bipartisan budget deal (besides the long term unemployment thing) was the apparent signal that the house and senate republican leadership were/will be trying to keep their extreme wing(s) under control, perhaps to increase the odds of a 2014 senate takeover. (And that the shutdown/debt ceiling fight was a bipartisan attempt to weaken the TP. I know this had been discussed but it was easy to ignore.)
The positive aspect is that the republicans have essentially hinted that they’ve mostly given up on their tactic of weakening the economy with threats to blow it up. This might improve the confidence of hiring managers a bit.
Amir Khalid
I also wonder if you have “five-star” hospitals in the US. You know, the kind that combine top-notch (or at least, top-dollar) care with fancy-hotel luxury accommodations.
fuckwit
@Bill Arnold: Not to worry. In PRESIDENTIAL elections, they ALWAYS tone it down: that’s how they ended up with RMoney instead of, say, Frothy Mixture, who much more closely epitomizes their positions and their base.
It’s in the Congressional and Senate elections where the R’s can’t help but let their freak flag fly. And I see no signs of them being able to control that anytime soon.
Flukebucket
I just had a guy tell me that before Obamacare an insurance company could not drop you for any reason other than failure of premium payment (or you lied to get the policy)
He says with Obamacare an insurance company can drop you anytime they want to for any or no reason at all.
I just always assumed that what insurance companies did once you got sick was keep you on the policy for the super low price of 10 grand per month or something like that.
What is the truth?
jenn
@Flukebucket: wow, that’s utterly backwards. No, it was far too common to cancel coverage pre-ACA (I don’t know how *common* it was, but however often it happened, it was too common) . There have been numerous articles on this in the past, particularly in reference to canceling insurance to breast cancer patients
Mnemosyne
@Flukebucket:
The problem was that the insurance companies treated “lied to get the policy” very, very loosely. Here’s what one insurance company told a woman was the reason they were canceling her policy right before her scheduled mastectomy:
So, basically, they canceled her for “lying” about things that were completely unrelated to her cancer, which gave them an excuse to cancel her policy before expensive treatment. Another story in that same link says that a man’s policy was canceled for “lying” about information his doctor never told him in the first place. There were also stories here in California of people having their policies canceled for “lying” because the patient found out they had a genetic condition, which the insurers decided they somehow should have known, so therefore the customer “lied” to get a policy.
So, yeah, you can tell your friend from me that he’s technically right, but completely full of shit, just like the insurers who canceled the policy of a cancer patient for “not list[ing] her weight accurately.”
Flukebucket
He also told me that there was never a time when you could not get insurance if you had a pre-existing condition. I guess he is technically correct but when somebody says they will be glad to provide you with insurance for a monthly premium of what amounts to an annual salary then that is the same as saying you can’t get insurance.
It is all confusing to me. All I know is that when the smoke cleared I wound up saving 20% on my insurance after getting it through the exchange and I have a lower deductible and less out of pocket expenses. I make too much money to qualify for subsidies but in my opinion it takes a sure enough asshole to complain about making too much money.
Mnemosyne
@Flukebucket:
Again, your friend is wrong — some people absolutely were denied insurance coverage at any price, especially if they were cancer survivors.
Weirdly, it sounds like he’s confusing some of the provisions of Obamacare that went into effect between 2010 and 2013 with what existed before 2010. He does realize that Obamacare was implemented in stages over several years and that the changes that have happened since 2010 were due to Obamacare, right? It didn’t just spring up fully-formed this October.
Flukebucket
He is a big time talk radio guy. Herman Cain, Neal Boortz, Hannity, Limbaugh. All of ’em. There will be no convincing him of anything and I am not trying. I just wanted to know as much as I could know in case it comes up again.
StringOnAStick
@Amir Khalid: Oh yeah, we have the top notch luxury hospitals you are referring to. I was talking to a Canadian (who lives here) about his recent experience with an emergency situation and 2 weeks in one of our local hospitals – he called it Club Med, I think mainly because you can order any food you want off the menu any time of the day or night.
I know US citizens who go to Thailand for medical tourism, most reported that the facilities were far nicer than they could afford to go to here.
japa21
@Flukebucket: To some degree he is correct. Many policies covered people except for those conditions that were pre-existing at the time coverage began. In some cases this would be for 6 months and in some for 1 year.
So insurance could be gotten, but it wouldn’t cover what may well be the most important thing as far as the insured was concerned.
In some cases, it also made a difference how long ago you had last received any treatemnt specifically for that condition. Again, if you received any treatment in the past 6 months to a year, ongoing treatment would not be covered for a length of time. If there had been no treatment during that time span, it would be covered.
It should be noted that these terms were most common in group coverages, mainly because employers didn’t want to lose prospective employees because of prior medical treatment but at the same time, if a person was under medical treatment now, they were concerned about loss time and productivity, so it was a sort of compromise.
Many individual policies differed.
Most of the cases where people lost their coverage for some of the reasons mentioned above were where they had individual policies. Many insurance companies would not do that to an employee of a large employer group because they were afraid of losing the business of the whole group.
jenn
@Mnemosyne: Yeah, I remember some woman with breast cancer, I think it was, who had her policy canceled because she didn’t list acne on her insurance application. It’s not like she had severe acne which required treatment, either. Bastards.
The Red Pen
@Richard Mayhew: So, if a provider needs a certain number of contracted providers to offer a policy, then what happens if they all “go wingnut” and leave the network. Does that leave the policy-holders stuck without providers?
This is a nightmare scenario that wingnuts like to promote.