That is not how it works in my neighborhood at all. When a patient goes out of network, the patient pays the doctor’s fee. It is the patient who is short changed by their own insurer with their fake usual and customary designations. They are cheating their own customers.

I too have seen hospitals leave money on the table by hiring ill trained people to deal with the payor critical functions. It is not rational but hospitals are run by human beings. A large part of what keeps the dysfunction going is the reaction noted above in which the “providers” lash out with blame that is accurate as far as it goes but never get around to looking at their own dysfunction and cleaning up their business procedures.

But when we do clean them up, we are still left with an insurance industry that makes money by collecting premiums, not paying out claims, and which is paradoxically happy to cheat and frustrate it’s real customers as soon as they get sick and shift from being only premium payers to being also claim makers. It is a case of customer service being bad business since if they go away at that point, they insurer is more profitable.

Which is exactly why these bills that require everyone be their customer is horrible. People should be free to walk away from the abuse and take their own chances if they want. Insurance is gambling and most players lose.

Brandon, you make some good points.

But first I have to make clear, I am not an insurance person. And I am not a provider person. At this point in my career, I am simply my own person.

You are right that this is a very simplified view and how great would it be if solving all our problems was as easy as having a good, well-trained staff? I am not ‘blaming’ providers for anything. The reason I brought up the provider side is because registration errors and unnecessary procedures drive up health care costs. The prohibitively expensive cost of care is a major issue in the current debate.

You also make an excellent point in observing insurance companies have little to no incentive to sit down with providers. I would say on the surface that is true. But insurance companies without providers are soon also going to have no members, so it does behoove them to cultivate positive and mutually profitable relationships.

I’m not implying health care providers don’t want to sort things out. It would not be fair to make a blanket statement like that. Unfortunately, there is so much animosity, on both sides, that I do not know how a détente is going to be achieved. Insurance carriers should want to discuss these issues because good business is about good relationships. If they were more responsive to providers, a lot of their Provider Relations headaches would go away.

To suggest that providers fall under that same umbrella (because they can’t register people properly) is simply absurd.

I wish it would be as simple as training admin staff to register people properly.

I’ll be happy to sit down with the insurance company and sort out our differences. But the only ones that have absolutely no interest to sit down with providers is the insurance company. The article was clear that there is absolutely no motivation to fix anything on the insurance side. The provider side, on the other hand, is eager to sit down and try to find a common ground.

So don’t imply that health care providers don’t want to sit down at the table and sort out issues like, why has reimbursement for doctors have consistently gone down in the last decade.

I’d be happy to hear the answer and try to find a solution for it. But why would an insurance carrier want to discuss that issue.

But hospitals are not rolling in dough. They are impoverished here in New Jersey, where my professional experience has been. Between the reduction in Medicare reimbursement and state aid and financial carelessness, 21 hospitals have closed in New Jersey since 1997.

I wish I was incorrect, but what I describe has been my experience.

Why would hospitals leave that money on the table. Makes sense only if 1) Ms. Cooper is incorrect about it, or 2) hospitals are rolling in so much dough that they don’t care about this innefficiency.

-Steve

I do know that the problems boil down to a tolerance of mediocrity, the same pervasive issue that affects so much of any service industry.

I also know that name calling, partisan attacks and an unwillingness to think in new ways are never going to get us anywhere.

So, the questions are
“What are some possibilities to get them to work together?”
“Is it possible to get them to work together without onerous regulation and stiff penalties (ie, not by forcing them via government)?”