You are not the only one who finds medical insurance difficult.
I have been around medicine my whole life. My father was a plastic surgeon as well. Back in his day 30 years ago when a patient had insurance, he billed insurance for x amount, and they paid x amount.
What a concept.
When I started my practice I got on to as many insurance plans as I could. It was a way to network with patients and grow my practice. But I noticed the older doctors were trying to get off insurance plans. You’ll see a lot of the great internal medicine doctors don’t take any insurance anymore- they have become “concierge” doctors. Why?
- Because most insurance does not pay doctors well.
- They will only pay a portion of the billed amount. I could charge $100,000 for a surgery. But insurance plans have what is “allowed” for each CPT code. This is the maximum I can get paid. And it is a small number.
- This has caused doctors to need to increase volume to make a living. Doctors don’t want to slam a gazillion patients into a day. They have been forced to do that to make ends meet. Particularly in Silicon Valley, rents are high. Costs of employees are high. Don’t forget malpractice, office supplies, medical supplies, etc etc. Most medical offices have at least one employee dedicated just to billing insurance.
- When you are a solo practicioner like I am, your reimbursement by insurance is even lower. The large groups like Stanford and the Palo Alto clinic have better negotiating power with insurance plans to get better reimbursement.
- When I am on an insurance plan, I am not allowed to balance bill the patient. Let’s say I do a long breast cancer reconstruction case. Bilateral. As a surgeon, my surgery code with insurance includes ALL of your visits pertaining to that surgery for 3 months. My visit to the hospital for the next day or two after surgery. All of your follow ups in my office. When I do a tissue expander I see you every 2-3 weeks. I use supplies: saline, syringes, needles, local anesthetic. I am not allowed to bill for any of those costs.
- You have to submit, and frequently resubmit claims to get paid.
You can still go to any doctor you want if you are on a PPO plan. Even if they are not “on” your plan, they will be covered, though usually at a lower percentage. We are considered “out of network.”
I know you pay high monthly fees and deductibles and copays for your health insurance. We must for our family. But insurance is not passing that money on to the doctors. Most general surgeons make about $400-500 for a hernia repair. I just did a bilateral breast cancer reconstruction case. I saw her for a preop for an hour. The surgery took about four hours with mastectomies. I saw her multiple times in the hospital. Then I saw her in clinic to expand her every 2-3 weeks, for a total of 8 post op visits I can’t bill for. My supplies were not reimbursed. I was paid $700. For my skin cancer excisions, I am paid almost the costs of the sutures and supplies I use. My ER call visits I frequently don’t get paid at all. It is pro bono work.
All doctors pay to go to medical school, which takes four years after college. All residencies are a minimum of three years. All surgery residencies are a minimum of five years. Plastic surgery is an additional fellowship, so we train even longer. We give up the decade of our 20s to living in a hospital to learn our craft. I trained in the days of 100+ hour work weeks, living in the hospital. We delayed our lives- marriage, buying a home, kids.
It is tragic to see what is happening. Older seasoned doctors retire early, when they are at the height of their career, due to poor reimbursement. Doctors do things out of their specialty, to try to get into the cash pay areas.
Please see the link under. This is a group of general surgeons discussing hernia insurance reimbursement. http://www.generalsurgerynews.com/index.asp?section_id=67&show=dept&issue_id=109&article_id=4089
So why do we not take insurance plans? Because we can’t if we are to survive with a shred of our ideals intact. I need to pay my overhead. I don’t want to become a patient mill. I want to give my patients the “concierge” medicine they deserve. Surgery is a scary thing, particularly when recently diagnosed with cancer. These patients should not be rushed.