Thursday, March 27, 2014

Do you know your doctor's expiration date?

CMS is considering new rules to protect seniors if their Medicare Advantage Plan drops their physician.  I think that's a great idea, and wish everyone had such protection from network changes.  I was pretty sure I'd written something about that, but couldn't find it posted.  After digging through old files, here it is.

January, 2012

Imagine going to buy milk at the store, only to find that none of the cartons are marked with an expiration date.  You ask a clerk about it, only to be told that the dates exist, the store knows what they are, but that they are a trade secret and they can't disclose them to you.  All they will tell you is that the milk is not expired as of today.  "How," you ask, "will I know if it is safe to drink tomorrow?" 

"Check back tomorrow", is the answer.  "All we can ever tell you is whether your milk is expired as of the day you ask."

Such an arrangement would be absurd on its face, and if a store attempted to impose such conditions a regulatory or legislative remedy would surely not be far behind.  But in one industry such absurdity is the norm.  Do you know your doctor's expiration date?

Most private health insurance plans are circumscribed by networks.  Go outside the network and you face a steep increase in out of pocket expense through  copays or deductibles. In some plans the out of network coverage is so restricted that patients are functionally uninsured.  Most people know this and quickly learn to identify in-network providers.  But those networks change over time, depending on whether or not doctors and insurers continue agreeing to terms.  And included in those agreements are expiration dates.  If no renewal agreement is reached the contract expires and the provider drops out of network.

What notice do patients get when that happens?  Whatever their doctor feels like giving them.  Maybe they'll tell you when you make your next appointment, or maybe not.  As the paperwork repeats ad infinitum, patients are solely responsible for managing their insurance, and patients are solely responsible for payment.  Even if you've seen a doctor a hundred times and checked your insurer's web site to verify their network status yesterday, nothing guarantees that they are in network on the day of your appointment save checking with your insurer on that day.  Realistically, you probably won't find out until you get an Explanation of Benefits statement from your insurer stamped "Out of Network" followed by a hefty out of pocket medical bill.

What makes such circumstances frustrating is how unnecessary they are.  By simply disclosing the expiration date of the provider-insurer agreement, people would know when they needed to check to see if it renewed.  Not only could they avoid hundreds or even thousands of dollars in out of pocket expenses by being better able to avoid out-of-network physicians, they could improve the continuity of care.  Knowing at once if a provider had dropped out of network would allow more time for selecting and transferring records to a new provider, it could be done ahead of time rather than starting the process on the day you realize you need treatment and go to make an appointment.  All that, just from disclosing a date.

The only argument I've seen against such disclosure is that contracts between insurers and providers are trade secrets.  According to that logic, the contracts must remain secret to prevent collusion on prices.  I won't argue for or against that point, but I'd observe that the contract expiration date has no bearing on it.  What is the harm in disclosing an expiration date?  Is the market for milk screwed up because people know ahead of time when a particular carton will go bad? 

It's worth thinking about, because paying medical bills out of pocket because a physician's office didn't disclose they dropped your insurance  stinks worse than rotten milk.

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