In America, we are “supposed” to have a choice as to who and where we receive our medical care from, right? We have a choice alright, but many times there’s an additional price that we have to pay for that choice!
For example…let’s say that you (the patient) have found a great healthcare provider and you wish to obtain your medical care from this particular healthcare provider, only to find out that your insurance may not pay for any or all of their services, because;
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The Healthcare Provider is not a contracted in network healthcare provider within the insurance company’s preferred provider network; and/or
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You insurance plan may not include “out of network” benefits
These two scenarios means that a patient will have to pay part or all of the charges incurred, out of their own pocket!
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No “Out of Network” Benefits = Patient pay 100% of out of pocket charges incurred for services rendered from a healthcare provider who is not in network with your insurance company
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With “Out of Network” Benefits = Patient pay a higher percentage of out of pocket for charges incurred for services rendered from a healthcare provider who is not in network with your insurance company
The healthcare provider explains this information to the patient, the patient may or may not agree, and many times the patient ask the healthcare provider to “get in network and become an in network provider.”
The simple truth is, and patients need to understand, that it’s just not that easy, although it would be nice to be that easy.
Healthcare providers must weigh the cost and benefits associated with becoming an “In Network Provider.” The challenges that healthcare providers face and must take into consideration, are:
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Willingness to accept lower reimbursement rates from the insurance company, many times the discounted rates are much lower than the Medicare Allowables
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Many insurance companies tell healthcare providers that “they already have enough providers” within a particular area or region
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Insurance Credentialing for healthcare providers can be a long, drawn out and tedious process
The problem(s) with the above scenarios consist of;
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Lower Reimbursement Rates – Healthcare providers may not be reimbursed at a level that covers cost associated with their products, services and office overhead expenses
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Insurance Credentialing - Healthcare providers may not have the knowledge, skills and expertise in, what I refer to as “The Sales Game” to convince the insurance company why they should accept a healthcare provider as on “In Network Provider” and/or the insurance negotiation process
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Enough Providers - Many times this is just not the truth! Insurance companies tend to categorize healthcare providers based on their scope of practice and specialty. For instance, Orthotic and/or Prosthetic (O&P) healthcare providers are typically linked in the same category with Durable Medical Equipment (DME) suppliers, and DME suppliers tend to be a "dime a dozen.” There seems to be an abundance of DME suppliers all over the US, and most of these DME suppliers DO NOT offer Orthotic and/or Prosthetic (O&P), custom fabricated and/or prefabricated, medical devices. I know this for a fact because I actually research and call each and every one of the contracted providers to inquire about the products and services they offer, when I conduct my research for my clients. The results identify that 95% of DME suppliers DO NOT provide any type of O&P devices, and yet both specialties (DME and O&P) are linked in the same category...go figure!
In my opinion, someone needs to wake up and realize that Orthotics and/or Prosthetics (O&P) should be placed in a separate category and/or specialty, than Durable Medical Equipment (DME).
Why? Because providing custom fabricated orthosis/prostheses requires more substantial training, education, knowledge and skill, from a certified and/or state licensed practitioner, to successfully evaluate, cast, measure, fabricate, then fit and deliver the orthosis/prostheses to their patients, than a DME supplier.
I am not undermining DME suppliers, I respect what they do…however, Durable Medical Equipment (DME) is typically “medical equipment” that a patient can purchase or rent, such as; wheelchairs, canes, crutches, diabetic suppliers, respiratory & oxygen, hospital beds, etc.
Think of it this way…if you were/are a patient, and an amputee for example, would you want your custom fabricated prosthesis to be considered “medical equipment?” The prosthesis is actually a replacement of a member of your body that may have been amputated for whatever reason. A replacement device that can allow a patient to ambulate, and/or function in the same and/or similar manner as the patient was before the amputation occurred, a normal functioning state, if you will. That takes "professional" education, training, knowledge, skill and expertise...more so than a clerk who pulls an item off the shelf and delivers to a patient. They are simply not the same specialty!
Moving on…many times those who are not “thoroughly” informed, can only assume that Orthotic and/or Prosthetic (O&P) devices are just as simple as ordering Durable Medical Equipment (DME).
In fact, many times ordering physicians will write a prescription for their patient, hand it to their patient and tell them to take the prescription over to the Orthotic and/or Prosthetic (O&P) provider and pick up their device.
The truth is, there’s much more involved with providing Orthotic and/or Prosthetic (O&P) devices to patients than sending a patient over with a prescription and allowing the patient to assume the Orthotic and/or Prosthetic (O&P) device(s) is something the patient can go in, pick out and pick up. Especially, if the O&P provider wants to be reimbursed for their service, master medical policy(s) and maintain DMEPOS compliance.
That’s a wrap for this week…more to come later! Please tell me your thoughts on the “Feedback” comment space. I would love to hear what you have to say about this blog topic.
Until next time, have a fun and safe weekend!