How much are in-network provider fees and/or discounts?

[exofficio]

All of a sudden I feel extremely dumb. I'm trying to find out just exactly what the in-network fees are (and the implied savings by using an in-network provider) for a particular network. In this case, Humana, specifically HumanaOne in South Florida. They call this an Open Access Plus EPO network.

It turns out that a few years ago there might have been a standard schedule of fees for services performed by in-network providers. But today, it seems that each provider negotiates their own in-network rates. How is that even possible... Humana could not provide me with any specifics regarding 'approved' in-network fees for services; they redirected me to my provider to find out what the in-network savings is versus the out-of-network cost.

I am flabbergasted! How can I continue to sell a Humana HDHP not knowing what they could charge a client/member for an in-network service? After all, the claims dept doesn't even know, they leave it up to the provider to code it!

All I'm looking for is simple stuff: how much do x-rays cost in-network; b) how much is an office visit, in-network, primary of specialist, I don't care; c) how much is a cholesterol test, a mammogram, a freakin' PSA!?!?!

I've been telling people that the in-network benefit of an HDHP is not much more than a co-pay they were used to. Seems like I bought into the whole racket hook, line, & sinker... I am halting selling these plans until I get a satisfactory answer.

Now, before I blow a gasket expending any more frustration on the next carrier and end up halting all my freakin' sales out of some sort of principled ignorance... somebody please tell me that there is a schedule of in-network fees, or at least a published in-network discount for other major carriers.

Thanks!

 

[somarco]

There are no standard fees. Each provider negotiates their own fee structure with the particular MCO.

Macys doesn't tell Gimbal's what they pay for goods. Why should Humana tell Aetna (or you for that matter)?

Very few carriers will provide access to provider pricing. Even then it is only in a few areas, only covers a few providers and is only for the most utilized primary care CPT codes.

You can always ask and a carrier will usually give you a range of pricing for routine office visits. Beyond that you are dead in the water.

There are more than 10,000 CPT codes. Factor in the number of providers in a given area and there is no way to post a price chart.

This isn't Jiffy Lube.

Miami is a different cost area, but as a start, add $20 to office copays. Most routine lab work is less than $50. PSA's are covered (at least in most states) under the annual wellness benefit.

You can also use Out of Pocket as a rough guide, or you can use the CMS pricing and add 40%.

Or you can sell copay plans while more experienced agents who are not afraid to educate their clients run rings around you.

 

[Crabcake Johnny]

Here's an example of Aetna re-pricing.

 

[exofficio]

Thank you both for the replies!

I actually found a listing of 'typical' in-network charges through Humana's member section. Granted, each provider may charge something different, but at least I feel a lot better about the mystery.

Heading back for more kool-aid =)

 

[somarco]

Aetna has something similar for members. Humana's pricing tool for Rx is something I use on a regular basis for converting folks off Rx copay plans.

 

[Soaringagent]

How is HealthNet in CA in terms of negotiating rates for members?

 

[NewHealthStrategies]

This is a GREAT question! It will continue to be a "thorn" as more and more consumers move into HSA or consumer-driven plans.

Here is a primer.

In most every metropolitan area, and even if most non-urban areas, the doctors contract with carriers under the umbrella of what is known as a PHO or Physician Hospital Organization. Here is an example: In a metro area, one major hosptial system may have 1,500 doctors affiliated... their managed care professional will do all the negotiation with the carrier and arrive at a discounted figure that they BELEIVE all the physicians will agree to take. Once agreed upon, they send out inidivudal opt-in forms to each doctor who then INDIVIDUALLY decides.

MOST PHO's have very strict rules and agreement that Doc's will not go-around the PHO and contract directly, but it does happen and more so in the rural areas. Rarely do carriers have the man-power or money to contract individually with each doctor.

Beleive me, Doc's and Hospitals DO NOT want you to know what they have agreed upon, because one carrier will use it against them in negotiation... for example, BCBS might get a 70% discount but Humana only gets a 40%.

Doctors and already seeing an increase in patients calling asking what it costs for services.... which of course, most don't know the answer too.

Hosptials are seeing this also......

It's a part of the growing pangs what we will all have to live with as we move to consumerism.

What fun!

BTW: Aetna is the ONLY carrier with TRUE transparency in the market. They list the actual price on their site for members.... not the "typical" or "average" or "CMS" pricing. This is an interesting point for HSA purchasers.

 

[Dave020]

Correction, Bob(s) below is/are correct on this. Actual NFR is really irrelevant. Thanks for letting me reconsider my thoughts on this. Client won't shop NFR on services given that they are all likely close and client knows his/her OOPM anyway.

I love this forum, I do learn things every day.

 

[somarco]

Fee's are predetermined either on a per diem basis or discount. When consumers start shopping on price as the primary factor everyone loses.

Will they fire their PCP when they find out the guy in the next building charges less? Or wil they keep the PCP but opt for the EDLP neurosurgeon?

Transparency is nice when you are comparing where to get your oil changed. But when it comes to medical treatment, I fail to see the value.

 

[Bob_The_Insurance_Guy]

#2 agrees with #1. I always tell them that the negotiated rate is per doc, per procedure, and while they won't be paying the flat $20 copay, they also won't be taken to the cleaners.

99.97% of my prospects/clients get it.

Those that don't, they get a Humana copay or Kaiser HMO plan.