Agreement Between Insurance Company And Hospital


According to a November 4 WSJ article, observing the state of North Carolina could be a good start. The staff health plan in North Carolina has about 727,000 people, including teachers, university employees and the state police. The North Carolina treasurer announced in October that he would pay hospital and physician payments related to Medicare`s reimbursement plan. The state treasurer said the new rates, starting in 2020, would average about 177 percent of Medicare`s costs, which is below the current average of 213 percent — which calls for an annual savings of $300 million. The hospital community N.C is predictably pushing back to prevent this. Recently, as a Medicare Advantage patient, I discovered that some insurers have contracts with their specialists to refuse transfers from certain medical practices. My doctor has written a referral for an ophthalmologist on my plan and the ophthalmologist`s office refuses to accept his dismissal stating that they have a contract with the insurer not to accept specialists whose names appear on an insurance company list. My family doctor`s office denies that this is a head-to-head problem. After waiting for this appointment for months, I was denied care unless I paid for it myself and had to deal with another specialized office. The office could not tell me how much the visit would cost if I had paid myself. Welcome to Real World Medicine 2019. Secret contracts, performance denial, false advertising for services, bait and medicine switch.

The United States spends more per capita on health care than any other developed nation and will soon spend nearly 20% of its GDP on health. Overall, Americans do not buy more health care than other countries. What they buy is becoming more and more expensive. Among the factors that fuel spending is the opaque way of setting the price of health care, a problem that is compounded by the details hidden in agreements between insurers and health care providers. The performance of hospital systems and health insurance funds can be immense. Even large employers like Walmart and Home Depot have not been able to cut costs because of hospital pressure. You are entitled to your hospital or mutual and you must always ask for an estimate of the cost of your treatment in private and public hospitals. As always, Anne, you ask a very pertinent question: “Who is the real payer of health insurance?” I will answer your question briefly about health insurance, not health care.

Both are used in a manner synonymous with each other, but often wrong. The actual payors are indeed the ones you mentioned, but employers pay a portion of the health insurance premium that is NOT charged to the worker`s income. I don`t know what the amount or percentage is, because it varies depending on the organization (and its culture). Therefore, given the current health care system, I do NOT rule out the employer being a “payer.” In the system we have with the employer today, the employer is the “insurance taker” because it selects the on-flight plans available in the insurance market, opting for the insurance seller, the broker (in many cases), the type of plan (s) that must propose and implement the plan (s) and fulfills many reporting obligations on behalf of employees.