<p>As a Kaiser member for 20+ years I had never seen an insurance claim, never had to question a bill. Now I am managing my mom’s health care with Blue Cross/Blue Shield and Medicare. I receive reams of paper in the mail, first with estimates of coverage then with actual payments documented. Even when everyone knows a procedure is not covered by Medicare, the insurance company requires that health care providers submit the claim first to Medicare. Only after it is rejected with they process the claim. The insurance industry must employ thousands of people who simply push these papers around all day and field calls from people like me, shocked at the waste and redundancy in the system. It’s daunting, and I don’t know how the elderly and sick are able to stay ahead of the tide. I suspect a lot of bills just get paid out of pocket when people don’t have the energy to fight the system anymore. Hail Kaiser if they can take over the market in this country. </p>
<p>Yes, I think that’s typical, CF. The advantage for the patient, at least what I have found, is that you don’t get the push-back for treatments or scans that you get when the insurer is picking up the tab. So the middle man still exists as far as the billing goes, but not so much for treatment decisions. The doctor doesn’t have to fight for every test like they might have to with traditional insurance. Since the insurers aren’t making money themselves by denying treatment- they get paid either way- they let the doc be the driver. </p>
<p>Momsquad, I am switching to Kaiser. The paperwork is way better. Network issues are better. ;)</p>
<p>I have an out of network issue that came up today with a doctor and Anthem. Going to cost me $250. My daughter needs a prescription and I dont want to waste any time chasing around doctors to find who is in my plan. </p>
<p>Kaiser is very optimistic for 2015. :)</p>
<p>Kaiser is getting better. My neighbor quitted his practice and join Kaiser.</p>
<p>
That’s not actually how insurance companies set rates for in-network providers. They’re set ahead of time, and they’re not negotiated on a patient-by-patient basis. The full fee that a provider quotes doesn’t have any effect on what he gets from the insurance company: if he bills a million dollars, he gets the negotiated rate; if he bills ten dollars more than the negotiated rate, he gets the negotiated rate. It really is the rate that he wants from patients who don’t have insurance (or have insurance whose network he’s not in).</p>
<p>There seems to be a significant variability by practice and geographic areas. In some specialties and some areas (like New York City) it can be very difficult to find and make an appointment with an in-network provider. Enough people will pay full fees that providers prefer not to joint networks.</p>
<p>Organizations that provide services and insurance aren’t anything new. That’s what early HMOs generally were, and any organization that did that would pretty much have to function as an HMO does. While opinions and experience vary, there’s a good hunk of the consumer market that is not at all fond of the HMO model.</p>
<p>There’s no built-in advantage to such an organization. The amount of administrative expense is going to be proportional to the amount of administration. Large group practices of doctors - even where they don’t take on the insurance function - have big administrative expenses. Even back in the '70s, when the earliest such organizations arose, it would be normal to have fairly large administrative staffs, and for the higher administrators to be quite well paid: often many times more than the highest paid physicians in the group. And that was when they were structured as partnerships owned by the doctors, who were effectively paying the administrators out of their own pockets. The fact of the matter is that administration of health care is a demanding undertaking, and when you pay less for management, you get less management, and wind up financially worse off than if you’d paid for it in the first place.</p>
<p>There’s something remarkable about the notion that vertical integration in an industry - which is what combining the provider function and insurance function in a single organization is - is going to be to the consumer’s advantage.</p>
<p>We’re talking about out of network charges. If the doctor is not covered by the patient’s insurance, they will bill that fictitious exaggerated list price that they used to start the negotiations with the insurer. And the patient will be liable to pay it.</p>
<p>If the doctor is in the patient’s network, they can bill anything they want, but they’ll get the price they previously negotiated with the insurer.</p>
<p>I think you’ll like Kaiser dstark, no more “out of network” and one stop shopping for every healthcare need. Plus you can email your doctors and usually get same day appointments, even nights and weekends, if you call in the morning. You won’t always be able to see your own doctor the same day, but at least you can get in there and get help when you need it. </p>
<p>Doctors like Kaiser because it allows them to control their time commitment. My doctor worked part time while her children were young and added patients as the kids got older. </p>
<p>Momsquad, I am pretty sure you are right. :)</p>
<p>The issue is not necesssarily the size of the network, although it can be, but we dont know who is in our network. My wife needs a breast exam. She has to make some calls now to see if the place she usually goes to is in network. </p>
<p>We have had 3 medical issues come up in the last month and the process of having to figure out who is in or out of network is ridiculous. </p>
<p>I am glad the new sign up period is coming up. Only a little more than two months before this nonsense is over for us. :)</p>
<p>We live in Marin County which is just north of SF.</p>
<p>My wife just talked to Anthem. To go in network for a mammogram, she has to go to SF.</p>
<p>Ha, Kaiser is somewhat overbearing with preventive procedures such as mammogram. They will automatically call when it’s time for a mammogram, and continue calling until an appointment is made. Calls from real people, calls from computers, letters in the mail- they don’t give up. </p>
<p>The LA Times created a database for Covered California policy holders to find which doctors participate in the various plans. Not sure if it helps with non-Obamacare plans but it has a lot of information. I think it works on mobile devices and Firefox but not Safari browser on PC.
<a href=“Find Obamacare doctors in California - Los Angeles Times”>http://graphics.latimes.com/dr-network/</a></p>
<p>Great link, momsquad.</p>
<p>To clarify, the database includes individual health plans sold in on Covered California, the California exchange. It does not includes group plans, even though group plans are now also governed by Obamacare/ACA regulations. And I don’t think it includes off-exchange individual plans.</p>
<p>The list isn’t accurate.</p>
<p>How so, dstark?</p>
<p>dstark, just wanted to send good wishes for the medical issues your family is dealing with, to be resolved soon and with good results.</p>
<p>My wife’s opthamologist is on the list and she isn’t in network for Anthem Covered Cal plans or off exchange plans that are similar to covered cal plans. </p>
<p>That is one case. I am sure there are others. If you need cataract surgery, that is a $3,000 mistake per eye. </p>
<p>Alwaysamom, thanks. These issues aren’t major. Pain in the butt though. Everything will be resolved. I would prefer Canada. 
Thanks for the good wishes. </p>
<p>What a mess. Here is the link to the original article, lots of people misled about coverage:
<a href=“Obamacare doctor networks to stay limited in 2015”>Obamacare doctor networks to stay limited in 2015;
<p>momsquad, that is an excellent article.</p>
<p>My wife went to a gp today. He is in his 60’s. He has his own practice, He takes all the plans and… He is not busy. He doesnt have enough patients. I dont get it. So many doctors dont take new patients and this doctor doesnt have enough.</p>
<p>I feel bad for him. </p>
<p>I wonder what’s going on with the guy (referring to dstark’s GP in the Bay Area who doesn’t have enough business). Does he take Medicaid?</p>