Socialized medicine foe goes to Canada to fix his hernia

HCProf

Council Hall
Sep 2014
29,471
19,017
USA
Question: Should doctors be free to set their own rates?
Doctors really don't set their own rates. Our billing is complicated. First of all, they contract with a insurance company at a discounted fee in exchange for patient referrals. The fee is based on a formula called RVU or relative value units. The negotiations begin with a analysis of CPT codes or procedural codes. The formula consists of work (amount of expertise and resources), Practice expense (overhead) and Malpractice expense. Then you factor in the Work, Practice and Malpractice from a geographical aspect, such as NYC and Cleveland. The CMS sets the conversion factor every year. The formula looks like this:

(W + PE + M) X CF = Fee

This is done for each CPT code used by the Doctor. Doctors start their business with a professional fee schedule and when they contract with insurance companies it is quite a bit less but will hopefully balance it out with patient volume. This is what you see on your EOB as an adjustment. This is a standard business practice in healthcare of writing off the difference between the physician fee schedule and the contract fee schedule.
 
Apr 2018
13,358
3,521
oregon
Doctors really don't set their own rates. Our billing is complicated. First of all, they contract with a insurance company at a discounted fee in exchange for patient referrals. The fee is based on a formula called RVU or relative value units. The negotiations begin with a analysis of CPT codes or procedural codes. The formula consists of work (amount of expertise and resources), Practice expense (overhead) and Malpractice expense. Then you factor in the Work, Practice and Malpractice from a geographical aspect, such as NYC and Cleveland. The CMS sets the conversion factor every year. The formula looks like this:

(W + PE + M) X CF = Fee

This is done for each CPT code used by the Doctor. Doctors start their business with a professional fee schedule and when they contract with insurance companies it is quite a bit less but will hopefully balance it out with patient volume. This is what you see on your EOB as an adjustment. This is a standard business practice in healthcare of writing off the difference between the physician fee schedule and the contract fee schedule.
No offense, but I didn't ask how it currently is, I asked if doctors should be free to set their own rates. It's a yes/no question that reveals a lot about the person answering it.
 

HCProf

Council Hall
Sep 2014
29,471
19,017
USA
No offense, but I didn't ask how it currently is, I asked if doctors should be free to set their own rates. It's a yes/no question that reveals a lot about the person answering it.
There isn't a simple answer. It is complicated.
 
Apr 2018
13,358
3,521
oregon
There isn't a simple answer. It is complicated.
Not if you believe in liberty.
I believe doctors should be free to set their own rates. Same with plumbers, bakers, auto mechanics, etc...
Nothing complicated about it.
 
Apr 2012
61,831
47,417
Englewood,Ohio
That is what happened to another friend who was in Vegas for a business trip. She had exchange insurance at the time and her insurance did not cover out of State medical treatment. They wrapped her ankle and gave her 20 pain pills and that was it. The sickening part...she went straight from the airport to the ER and she still had to wait 2 weeks before the authorized hospital could squeeze her in. I made her come to my house so I could take care of her until she had her surgery. The ankle started to heal with a malunion and her foot was completely at a 90 degree angle. Even tho she had an appointment and was seen in the ER, the surgeon would not call in any pain relief for her. Thank goodness, I had a stash to give her. She suffered like a animal.

We had the same type of fracture..crushed and it was a completely different experience with my insurance from an employer. I fractured my ankle on a Saturday evening and was in surgery Sunday morning at 6 am.
She had an HMO. Many of them are restricted to certain Doctors and areas. But others cover you all over.
 
Apr 2012
61,831
47,417
Englewood,Ohio
Private insurance is private insurance, regardless of whether it is purchased on an exchange or provided by an employer. That said, there are different tiers of coverage that can be purchased.
You are right. I kust stated them below. It all depends on what you sign up for.. there arevarying degress.

But keep in mind employers are putting more on the backs of employees due to rising costs. That is why we need universal health care.
 

Southern Dad

Former Staff
Feb 2015
40,603
8,540
Shady Dale, Georgia
You are right. I kust stated them below. It all depends on what you sign up for.. there arevarying degress.

But keep in mind employers are putting more on the backs of employees due to rising costs. That is why we need universal health care.
As employers have to pay more in costs related to labor, the ROI on automation, outsourcing, and offshoring starts making more sense. The problem with Universal Health Care is that we have a large percentage of Americans that pay no federal income tax. What percentage are you going to hit them with? European countries have very high tax rates paid by everyone. If we put a 18-20% national VAT on everything except food what would be the result? Would the left scream that it is unfair to poor people?