Doctors that don't take ACA - Does it factor into your FIRE Plans?

[abhe8]

It is a bit unrealistic to think that the only healthcare you will need is elective surgery or emergency care related to trauma. Young healthy people get hospitalized for things they can't control all the time. They have a pneumonia and require breathing support.  They get influenza and are placed in an intensive care unit. They have gallbladder or kidney stone attacks, which often cannot be fully treated in an emergency department and may require surgery or other expensive procedures. And while emergency departments (freestanding and otherwise) take all comers, they do bill you for the services.  If you have no assets, the bill is no problem. However, if you have $1 million sitting in a bank account, you can fully expect the hospital to try to collect for services rendered.

Um, pneumonia or flu requiring icu and vent are not "common conditions" for young, healthy people. In fact, they are very rare for young healthy people.

And the gall bladder/stones is a great reason to go to the surgery center in OK.

[abhe8]

I also agree that the boutique medicine mentioned is already here. Lots of dr are opting out of taking any insurance. Cash for service. Patient can then file insurance paperwork if they want to. I'm sure we will see more and more of this. Remember, insurance is not the same thing as health care.

[Blonde Lawyer]

Some states require doctors to accept Medicaid as a condition of maintaining their license to practice.  I believe Massachusetts is one.  It also requires lawyers to provide a certain number of pro bono hours to keep your license.

[Gin1984]

Some states require doctors to accept Medicaid as a condition of maintaining their license to practice.  I believe Massachusetts is one.  It also requires lawyers to provide a certain number of pro bono hours to keep your license.

I can't find any evidence of that for Mass.  Do you know how many patient hours the MD is required to see?

[MoonShadow]

I also agree that the boutique medicine mentioned is already here. Lots of dr are opting out of taking any insurance. Cash for service. Patient can then file insurance paperwork if they want to. I'm sure we will see more and more of this. Remember, insurance is not the same thing as health care.

Actually, I've discovered that this depends upon the state.  I recently was referred to a radiologist, and rather than use my HSA, I was going to pay it out of pocket.  So my doctor referred me to one in Southern Indiana that offers a rather significant discount for cash-up-front scheduled services.  When I asked about taking the receipt and using it against my deductible, the receptionist said, "Well, you can try, but Indiana law now prohibits us from telling your insurance company how much your procedure actually costs, because it was a discounted cash event."  "So if they call to check, you can't talk to them?"  "Correct."

So that won't apply to my deductible either.  Oh well, it was a pretty good discount.

[goatmom]

I don't know of any state that requires you to take Medicaid patients.  I never heard of a state requiring pro bono hours either.

[Blonde Lawyer]

Here's the pro bono requirement.  It's a "should" but since it is part of our ethics rules, most people treat it as mandatory.  You can buy out of it though.

http://www.mass.gov/obcbbo/rpc6.htm

Edit:

I'm looking for a citation on the medical requirement.  I worked there in 2003-2004 with kids on medicaid.  Maybe the requirement was limited to the pediatric version of medicaid but I remember being told that my kids (meaning my caseload) had it good in Mass because doctors were required to take their healthcare.

Years later I found myself on the board of a medical facility in another state and a doctor speaking there confirmed that Mass required acceptance of those patients while our state did not.  I'm not sure if that is an old law, an ethical rule, or limited to kids or what.  If I find out more about it I will post it.

[brooklynguy]

Another NY Times article related to this topic:  "Think Your Obamacare Plan Will Be Like Employer Coverage? Think Again"

[GrumpyPenguin]

When I was looking for a primary care doctor in my area, I found a "boutique" place nearby that had a weird monthly membership fee. Good for them if they find people to pay it, I just looked on and am perfectly happy with my non-boutique doctors office.  Frankly if someone wants to pay some monthly fee so that they can be extra pampered when going to the doctors office, I couldn't care less.

[ltt]

I work in the medical field.  We don't take any insurance at our office.  Reimbursement is too low to make it work.  Too much paperwork.  Too much intrusion by insurance company.  We see plenty of medicaid patients who just pay out of pocket.  If you want to see a mental health provider who takes insurance you will be waiting months.

And this is how it should be.  The doctor charges a reasonable rate so that people can pay out of pocket.  No dealing with insurance companies.  I do not know why either presidential candidate hasn't brought this up.  Forget about the expensive premiums and outrageous hospital bills---why won't either candidate mention this?  People will not need insurance if rates are reasonable.  Once a third-party member (insurance companies) arrived on the scene, costs went haywire.

[nancy33]

With Covered CA plans, like Mike said, the insurance will show as active if a patient pays one month premium for up to 90 days, the insurance will authorize everything, pay the doctor for the visits, and then demand all the payments back from the doctor. If the doctor doesn't pay the insurance company back, they will just deduct it from future payments for other patients. So, as a patient, you could pay one month of premium, never pay a premium again and get thousands of dollars of treatment, surgery, etc. over 90 days, the doctor would bill, get paid by the insurance, and then have to pay all of that money back to the insurance plan and go after the patient who is never going to pay because they weren't even willing to pay more than one month of insurance premium. So why would any doctor accept Covered CA unless it was already an established trustworthy patient. It will bankrupt a practice in short order. Quite possibly what it was designed to do.

[LeRainDrop]

I don't know yet whether it will factor into my FIRE plans, as I expect at least some changes in the ACA and/or plans that are on the exchange in the next few years.  However, it was the deciding factor in my decision of whether or not to elect COBRA after leaving my previous job this year.  See, COBRA is quite expensive, so I went on the Georgia exchange to see my options.  Hey, there actually were over 60 plans available, and many of them had reasonable premiums, though most had associated high deductibles (which doesn't mesh well with the remainder of my medical year).  I clicked on the provider list for every single exchange plan and discovered that none of my doctors are in any of the networks.  Well, I wasn't about to disrupt my treatments or change the doctors whom I love, and since I could afford the extra cost of COBRA, I stuck with that.  (I'm just on sabbatical and planning to get another job so expect to get better health insurance then.)

[abhe8]

I work in the medical field.  We don't take any insurance at our office.  Reimbursement is too low to make it work.  Too much paperwork.  Too much intrusion by insurance company.  We see plenty of medicaid patients who just pay out of pocket.  If you want to see a mental health provider who takes insurance you will be waiting months.

And this is how it should be.  The doctor charges a reasonable rate so that people can pay out of pocket.  No dealing with insurance companies.  I do not know why either presidential candidate hasn't brought this up.  Forget about the expensive premiums and outrageous hospital bills---why won't either candidate mention this?  People will not need insurance if rates are reasonable.  Once a third-party member (insurance companies) arrived on the scene, costs went haywire.

Sure, this is very common in mental health, but new visits may be $300 and follow up $100, so it depends on what you consider "reasonable." And often the patient takes their receipt and files it with their insurance company themselves.

[swamimeister]

I don't worry about it as I'm a long way from ER and hopefully ACA will be dead and gone by then. I also don't go to doctors unless I wake up there, which is covered under just about any insurance as initial ER treatment. For surgery not paid for by someone who has injured me I figure I'd go to that pay cash hospital run by doctors in Oklahoma that doesn't take insurance, reasonable prices and top notch service from what I've heard. I want nothing to do with health insurance as it currently exists in this country under ACA, negotiate price and pay on a card for 2% discount is my preferred method.

I choose to pay the tax which is about $700 for this year. I haven't had insurance for 11 years. Have paid cash for a couple of minor things that came up and have a great dentist in Guatemala. I took a look at the Oklahoma hospital website and the prices look good for the US but still looked to be more than double what you can find in other countries. And contrary to the belief of many, the US doesn't have the best healthcare in the world. I refuse to buy into this scam because it doesn't offer much that I would want. I prefer to lead a healthy lifestyle and usually cure myself naturally. Yes, there is somewhat of a gamble with my approach but aren't many of our life choices. I'm 59 and feel that the longer I go without insurance, the cup just gets more full.

[GrumpyPenguin]

Huh. I think without health insurance, a couple terrible bouts of kidney stones that need to be surgically removed or a cancer in the US would bankrupt most folks. 

[swamimeister]

Huh. I think without health insurance, a couple terrible bouts of kidney stones that need to be surgically removed or a cancer in the US would bankrupt most folks.

 If you feel soreness in the kidney area similar to muscle soreness, without being able to relate it to physical activity, you may be developing kidney stones. If the soreness worsens the next day, that's more telling. Kidney stones often begin to develop due to dehydration so the first thing to do is start drinking a lot of water. Keep it up for several days. There are also herbs that will dissolve kidney stones. Check with a local acupuncturist or Chinese herbalist for those.
 
 To help prevent cancer, stop ingesting sugar in all its forms. Stop putting chemicals on your body and limit breathing in chemicals as much as you can. Limit the stress in your life and do things that calm your nervous system. Keep your inner body clean. Some cancers seem to be genetic and some people will get cancer even if they lead a cancer preventative lifestyle. When someone gets cancer, it's up to them to decide how they want to address it. I believe that I would chose natural alternatives to the immune system destroying drugs and radiation that are the norm in allopathic treatment.

 So, "healthcare" (insurance) doesn't often provide me with what I want in order to live a healthy life for as long as possible. I could get in a serious accident and be unable to travel to another country for treatment. There's my gamble. But I'm not willing to pay probably a minimum or $500 per month plus go through the stress of the US healthcare system to give me the "security" that insurance will take care of me if that were to happen.   

 I'm not necessarily advocating that everyone look at this issue as I do but I do advocate everyone to learn about true healthcare and take the time to tune into your body.

[goatmom]

I work in the medical field.  We don't take any insurance at our office.  Reimbursement is too low to make it work.  Too much paperwork.  Too much intrusion by insurance company.  We see plenty of medicaid patients who just pay out of pocket.  If you want to see a mental health provider who takes insurance you will be waiting months.

And this is how it should be.  The doctor charges a reasonable rate so that people can pay out of pocket.  No dealing with insurance companies.  I do not know why either presidential candidate hasn't brought this up.  Forget about the expensive premiums and outrageous hospital bills---why won't either candidate mention this?  People will not need insurance if rates are reasonable.  Once a third-party member (insurance companies) arrived on the scene, costs went haywire.

Sure, this is very common in mental health, but new visits may be $300 and follow up $100, so it depends on what you consider "reasonable." And often the patient takes their receipt and files it with their insurance company themselves.

Well, some patients do file for out of network benefits.  Medicaid patients can't.  Obamacare patients can't.  Many of the Medicaid and Obamacare patients prefer to spend the money and get the care they want. They see physicians not physician extenders.  They get to choose their physician. This is nice although I certainly would not consider it a "boutique" practice.  Just good medical care.  They pay the office visit fee but all labs, xrays, and meds are covered through the insurance.  That is the majority of medical bill usually.  Many of these patients are not poor despite being on these programs.  As we see on this forum - people can have money - lots of it sometimes - and still qualify for medicaid. At least in my state.  Or family members are picking up the tab.  We see a percentage of people for "no cost" which is not seen often these days.   I agree - it is nice to cut out the insurance company from the picture.

[Ursus Major]

Well, some patients do file for out of network benefits.  Medicaid patients can't.  Obamacare patients can't.

I believe this is not correct as far as Obamacare goes. If you have a PPO under Obamacare, you should be able to get out of network benefits.

[Spork]

Well, some patients do file for out of network benefits.  Medicaid patients can't.  Obamacare patients can't.

I believe this is not correct as far as Obamacare goes. If you have a PPO under Obamacare, you should be able to get out of network benefits.

That was my original reaction as well.  Then I remembered: In my state, the one and only ACA supplier dropped all of its PPO options.  So... at least in my case, this is probably true.

[goatmom]

Yes, it could be by state.  I am not that familiar with options outside my own little corner of the world.

[obstinate]

It is a bit unrealistic to think that the only healthcare you will need is elective surgery or emergency care related to trauma. Young healthy people get hospitalized for things they can't control all the time. They have a pneumonia and require breathing support.  They get influenza and are placed in an intensive care unit. They have gallbladder or kidney stone attacks, which often cannot be fully treated in an emergency department and may require surgery or other expensive procedures. And while emergency departments (freestanding and otherwise) take all comers, they do bill you for the services.  If you have no assets, the bill is no problem. However, if you have $1 million sitting in a bank account, you can fully expect the hospital to try to collect for services rendered.

Um, pneumonia or flu requiring icu and vent are not "common conditions" for young, healthy people. In fact, they are very rare for young healthy people.

Hell, they're relatively rare for old people.

[1kickassgal]

I manage a medical practice in Texas and also have experience doing our billing.  I can add a little light onto this subject, as I have the same concerns on a personal level as well.  First of all, yes.....the rates SUCK on BCBS HMO product.  That is why many docs won't take it.  In some instances, it's less than Medicaid and we would lose money on each patient seen who comes in with Blue HMO.  The other big reason the Exchange plans are lousy deals for docs - let's say patient comes in and their benefits are verified.  If they don't pay their premiums for the month they are seen, the insurance company will cover that cost.  The second and third month, even though they show "active," if the premiums are not up to date, the doctor has to GIVE BACK the money they have been paid by insurance.   So we have learned to collect upfront from patients if they are in this period and we happen to find it out. 
Next issue - HMO's in general, or EPO's now.  Aetna and United both have EPO's in Texas.  Higher benefits with a referral.  So do the patients know that they need a referral?  Do they come in with one?  NO!  So we have our employees call their PCP's and spend countless hours helping patients secure their referrals so that they can receive care.  We have patients come in with no wallet, no method of payment.....expecting to be treated.  I can't walk into a grocery store, and expect to walk out with my cart full of food and expect to be "billed."  This all affects the bottom line and the ability of medical offices to pay their staff and their ever-rising costs of staying compliant.  The costs are mounting every year.  We spend thousands and thousands of dollars just to utilize an EHR system and then more money on top of that for the extra staff it takes to use it.  Doctors are spending hours each day beyond patient care documenting what is required.  Then add ICD 10 on top of that and now you have to document not only that you broke your nose, but how (altercation, falling from a building, accidental, etc.) 
I know I'm ranting - but it's important for people to understand the other side of this.  For every 100 claims that we send out, I will get at least 10 to 15 back requesting either medical records or being held or denied for multiple reasons.  Most, with time and effort, will end up getting paid.  But....they bank on the fact that most offices will have to let some of these claims go because there is a break-even point where you can't pay your staff to use any more of their time on a $68.00 claim. 
So the guy on this thread who said they don't take insurance - no it's not being lazy - they are trying to provide care and stay in business.  We are surgeons so it would be more difficult for us to operate under those parameters.
So yes - I think the insurance issue should be prominent in your mind as you are planning for FI.    The talk is that premiums will rise significantly in 2017, and the exchange will shrink in competition.  Be very careful and research what's available.  If you get cancer, do you want the ability to be seen at M.D. Anderson in Houston (for the Texas folks).  Well check your plan, cause most likely you won't be going.  And if a doctor IS willing to take such reduced rates......gotta wonder why.

[projekt]

But....they bank on the fact that most offices will have to let some of these claims go because there is a break-even point where you can't pay your staff to use any more of their time on a $68.00 claim. 

And then, oddly enough, the office sends the patient a bill for $68.00.