Attack On Out Of Network Doctors

By: G. Keith Smith, M.D.

A patient who wanted to have a procedure at our facility asked us to file insurance. We discovered that if she had her surgery at our facility rather than at an “in network” hospital, her deductible would have been $3,000 instead of $1,500, her copay would have been 50% of the charge rather than 20%, and she had to agree to a 25% penalty for coming to the Surgery Center of Oklahoma rather than one of the hospitals in the network. Never mind that the hospital would receive multiples of our fee from the insurance company, and the patient’s copay at the hospital was more than our entire charge.

This insurance company (a huge national company) made it clear when they came to Oklahoma that they were not interested in contracting with any facilities that were not hospitals or affiliated with hospitals. Because of this, our facility is out of network. In order to steer patients to in-network facilities, insurance companies financially punish patients for wandering outside.

These networks were ostensibly devised to control cost and to guide patients to quality care. They have done the opposite, as you can see by comparing what you were charged for your medical care or insurance premiums 10 years ago with what you are charged now. Fewer and fewer good physicians with busy practices have remained in these networks as these organizations cut their fees every year.

Cutting the physician fees introduced a soft form of rationing that was central to the profitability of the carrier-PPO concept, as preposterously low payment to a physician for a service resulted in little of that service being rendered.

You may well ask, “If profitability is what drove these carrier/PPO’s, why would they want to pay more at a hospital? This doesn’t make any sense.”

It doesn’t make sense until you understand that the giant hospital bills gave the PPOs an opportunity to profit from their repricing scam, charging for the extent to which they are successful in “discounting” these inflated bills.

The out-of-network penalties didn’t work well at first because our acceptable profit margin was so low that even what the PPOs and carriers considered giant penalties weren’t sufficient to put us in the red. The carriers started to punish patients more and more aggressively, but our prices were so low that we could work with patients individually, making sure that their cost for working with us out of network was less than if they stayed in their network at the more expensive hospitals.

While these punishments were limited by statute, the carriers found ways around them that no insurance commissioner felt like challenging. Most of the funding for state insurance commissions comes from fees paid by insurance carriers, not taxpayers, and as the proverb says, “Whose bread I eat, his song I must sing.”


About the author

G. Keith Smith, MD is a board certified anesthesiologist in private practice since 1990. In 1997, he co-founded The Surgery Center of Oklahoma, an outpatient surgery center in Oklahoma City, Oklahoma, owned by 40 of the top physicians and surgeons in central Oklahoma. Dr. Smith serves as the medical director, CEO and managing partner while maintaining an active anesthesia practice.

In 2009, Dr. Smith launched a website displaying all-inclusive pricing for various surgical procedures, a move that has gained him and the facility, national and even international attention. Many Canadians and uninsured Americans have been treated at his facility, taking advantage of the low and transparent pricing available.

Operation of this free market medical practice, arguably the only one of its kind in the U.S., has gained the endorsement of policymakers and legislators nationally. More and more self-funded insurance plans are taking advantage of Dr. Smith’s pricing model, resulting in significant savings to their employee health plans. His hope is for as many facilities as possible to adopt a transparent pricing model, a move he believes will lower costs for all and improve quality of care.

About Concierge Medicine Journal

Concierge Medicine Journal (CMJ) curates breaking concierge medicine news, and editorial opinion on a wide variety of topics relevant to the practice of Concierge Medicine.

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