Speaker 1 (00:00:01):
Hi everyone. Welcome to Hernia Talk Live. My name is Shirin Towfigh. I’m your host for our weekly Hernia Talk Live question and answer session. I am a hernia and laparoscopic surgery specialist. Thank you to everyone who is joining me live on Facebook Live as well as on Zoom. You are also hopefully following me on my Twitter account and Instagram account, both at hernia doc. And I hope that you enjoyed today’s session because I was asking about different topics that people would like to know about and one topic really sparked my interest. It never really occurred to me to talk about insurance, but it’s definitely something that my patients and I deal with on a daily basis. And so I thought that now would be a good time to review it. So please submit your questions as they come through. I will answer them. I’m happy to answer any non-insurance related questions as well, but there’s such infrequent times when I can actually talk about insurance because that’s usually not something that I personally do.
Speaker 1 (00:01:10):
Usually my office takes care of a lot of that, but I thought that so much there’s so much misinformation, disinformation about what your rights are, what you can do, what are kind of access you can have to care. And I hope that I can help clear it up. So just a little bit of a background. In residency training, we get exposed to a wide variety of care. We work at a hospital that is public hospital and that care cares usually independent of your insurance status. We train at an H M O type hospital or Kaiser Permanente where you have to be a member and it’s like member-based care and it’s very kind of regimented as to what care is provided in that system. And then we work at a tertiary care hospital where it’s a lot of transplants and rare cancers. And so in those patients they tend to have a lot of private insurance, some public insurance, but it’s mostly private insurance or federal based insurances. We also train at the VA. That’s another type of publicly federally funded hospital.
Speaker 1 (00:02:32):
So it was kind of nice to see all the different, and we trained a community hospital, which is usually a very private or privately funded care. So it was nice as a resident to get to see all the different types of patients, the different types of care that was provided. And I’ll be very honest, there was a disparity in care depending on which hospital you went to. And as residents, we did feel like there was limitations to certain types of CAT scans and MRIs and lab studies and specialists that were available in the more publicly funded hospitals than in the privately funded hospitals. The care that was given at the publicly funded hospitals tend to be less expensive than the care given in the privately funded hospitals. And that just was a limitation of our resources. And this, I’m talking United States here, so that was kind of interesting to see.
Speaker 1 (00:03:30):
But we never really understood the finances behind giving care to patients. So as residents, we tended to provide the same care regardless of where we were rotating and didn’t understand that this which surgeon attending how they were reimbursed for surgery at the county hospital versus how they made money at the VA hospital versus how they made money working at the big university hospital. So it was kind of interesting to experience, but we didn’t really have very good insight into any of it. So then I started practice and in practice you start to look at, you know, you’re starting to finally making money, right? You’re paying off your student loans and as doctors, surgeons, the care that you give is often directly related to to the reimbursement that you get either directly or indirectly. So my first job was at a county hospital, the largest county hospital in the United States.
Speaker 1 (00:04:38):
I was on a salary. So if I saw one patient or 2000 patients, I got paid exactly the same. There was no incentivization to see more or do less or anything like that. We just showed up to work. We were told how much work you had to be done. You did this many clinic days, you did this many operation days. We took this many calls per month and that’s how we made money. I was basically a salary. And because it was a county hospital, the patients were also able to get care regardless of their insurance status. So regardless of their immigration status or insurance status, any status. So that part was really nice because I never spoke to the patients about money insurance coverage or anything like that. The hospital probably should have spent some manpower behind it, but that was not the purpose of a safety net hospital. And so as surgeons, you offered the care that you felt they needed understanding that as an emergency doctor, you were giving excellent care. As an elective doctor, they were like for every one patient we operate on, there were probably hundreds of people on a wait list. And so the expeditious, there was no expeditiousness to elective care, but lifesaving care, cancer care, all that was really high end. Elective care, You were on a wait list and it took a while to get in.
Speaker 1 (00:06:05):
My next job was kind of a hybrid, so it was in a community hospital. I was still salaried. So that meant that I had a baseline salary. I wasn’t there to make the hospital money. I was there to teach and develop educational programs. And so there was no real incentivization for me to work harder clinically. But as I kind of became better and better at what I did education wise, they also understood that maybe I should be making more money for the hospital clinically because teaching doesn’t make the hospital any money. That’s basically free work. But seeing and operating on patients makes the hospital money. Just since I was an employee of the hospital, I was pushed to do more and more cases and operating more and seeing more patients in order to substantiate my salary, which was fine, but to me it seemed like I was in some ways not doing what my purpose was in that institution, which was to educate and build programs.
Speaker 1 (00:07:12):
So now I have a very different practice and up until now at the Beverly Hills Hernia Center, I was not that privy to health insurance disparities and how billing occurs and so on. But now I definitely know and my staff is very well educated about it because now I’m in private practice, no one’s paying me a salary. Every money that I make I work for and that helps pay for my loans and expenses, but also the staff that I have and the health insurance that I get them and the insurances that I need to run a business and my overhead and also billing company and so on. So I’m very much more in tuned with how much time I can spend with my patients and how much the quality of care I can provide them because no one is over me saying, you should be seeing more patients because there’s a quota that you need to meet.
Speaker 1 (00:08:22):
Just as an example of what surgeons are dealing with, at one point 80% of all physician graduates or I believe at least surgeon graduates, I’m not sure. I think surgeon graduates, 80% went into an employed position and I believe that number is close to a hundred percent. So everyone who graduates from residency is now employed, which means, kind of, the business of running medical practice is left to someone else. That’s probably a good thing in many ways because they don’t teach you how to do it in residency, I’ve certainly learned a lot, but in some ways it has institutionalized the way that we provide care because it has to be profitable to be able to pay for doctors to show up and operate and keep the doors open for the hospital. So there’s a little bit of push and pull as to who’s benefiting from these.
Speaker 1 (00:09:32):
So there’s a question already that says, I really need to connect with you, dear doctor, we will do it online. I will talk to your staff about that. Do you recommend future tests for a more accurate perspective? So what this person is referring to is I do offer what’s called online consults. So there are three ways of being able to see me as a consultant surgeon before you determine whether you need surgery. Number one, traditional, call the office or email the office. All the contacts are in my bio, come in, see me, I examine you, I review all your imaging, I look at your history, and then we determine a plan of care. It may include surgery. That’s a very traditional doctor-patient relationship. Because of the pandemic, we’re able to offer telehealth, which means if you’re in California, since I’m in California, instead of you physically coming in to see me, you can call the office, make an appointment, and we’ll do a virtual consultation with you being in another part of California, usually northern California because I’m in Southern California.
Speaker 1 (00:10:44):
And we can do this virtually because we prefer that you don’t drive and go out in public and so on and risk your potential, your life to try and see me for a consultation. So up until now, telehealth visits were not reimbursed adequately or even accepted by some health insurances. And because of the pandemic, telehealth or virtual consultations are now reimbursed, supposedly reimbursed at the same rate, the same reimbursement rate as an in-person visit, that will come to an end. I believe it’s still considered part of the pandemic emergency situation. They have not relinquished that. If anything, I think a lot of the hospitals like it because it’s less staff work for them in the hospital. But the insurance companies, I’m not sure that they like paying for so much virtual care because they see that as less costly than in-person care and they may want to reduce reimbursement to the provider for that.
Speaker 1 (00:11:57):
And then the third way to see me, if you’re outside of California, and that could be anywhere in the world, you can do what’s called an online consultation. So I do not have the ability to practice in another state because I’m licensed in California. I don’t have the ability to practice in another country because I’m licensed in the United States. So based on that, I can provide you with my interpretation of your imaging and your reports and so on. So if you’re outside of California, you can send me all of your information by email or mail or however you like it, and I will review everything and submit to you a report which is not considered a doctor-patient relationship. No insurance will reimburse it because they don’t approve of that type of kind of distance between the doctor and the physician, sorry, doctor and the patient.
Speaker 1 (00:12:51):
But it is my way of being able to reach out to you and provide you with some guidance and put it in very clear written form. You can then take that to your own doctor if you choose or take that and decide that maybe I can help you and come see me. Or maybe I’ll say, you know what, you don’t need to see me go see an orthopedic doctor or whatever. And that could be something that will be very helpful to you to kind of expedite your care so you don’t have to fly in from Florida or New York or Italy or wherever you’re coming from to just get a question answered.
Speaker 1 (00:13:28):
I currently have a lot of international patients that do that from I think Italy, India, Dubai, Singapore. I have two familiar one from Singapore, UK. I have two. So these are interesting to me. And then I do see a fair number of Canadians. Your staff also helps a patient with all the information necessary so that the patient comes to Beverly Hills. I don’t have any insurance, but I’ve tried my best to put some money aside. Okay, that’s a very good point. So let’s get started on just what is insurance and how we can kind of figure out how you can navigate the system. In December, I will have a guest who is amazing in navigating the healthcare system as a patient. And so I really look forward to her input and I hope that this session today provides some insight to you all for the next session.
Speaker 1 (00:14:31):
So how does health insurance work in the United States? So as far as I can kind of say, most countries have a socialized system. That means everyone kind of links into a publicly provided healthcare system. That’s not true In the United States. We do have Medicare, which is a federal system that’s limited to certain populations. For example, age over 65. But we don’t have a public system for everyone. And so if you go to France, if you go to the United Kingdom, there’s National Health Systems, N H S, you can go to China, Russia, they all have one system or a few programs with that are federally funded in the United States, Medicare is federally funded and you may or may not have to pay for some of your Medicare benefits, and that’s kicks in when your age over 65 plus. There are a handful of exceptions into that.
Speaker 1 (00:15:35):
There’s also in the United States publicly funded care for those that are unable to financially, that are financially distraught and cannot pay for it themselves. So that’s what we call Medicaid. It usually is based on some poverty level or income level or certain qualifications for children and certain diseases. So Medicaid and Medicare are the two federally funded programs. Everything else kind of falls in the middle. Most companies that are large enough will pay for your health insurance in the United States if you’re a full-time employee. So I pay for my employees, he health insurance fully. If you work for McDonald’s or Sears or GE, they all have health insurance, apple, Amazon, they all have health insurance that is provided to their employees. And depending on how big and financially stable the company is, they may or may not fully fund that health insurance. So that’s been kind of something that’s changed over time.
Speaker 1 (00:16:47):
And it’s one of those things that I believe the Affordable Care Act has mandate, which is that if you have a certain number of employees, you must have must provide health insurance to them. And if you provide a health insurance, you can provide anywhere from a fraction to a hundred percent coverage for them. That’s a good thing. That did not used to be the thing, the issue before, it used to be that you were kind of on your own even if you had a job. So now you have the majority of people covered. Almost everyone in the United States either has Medicare, which is age 65 or over usually Medicaid, which is financial based care, usually have to be at some poverty level. Usually we’re talking adults here or you’re getting healthcare through your insurance, through your employment. So if you’re not employed, not married to someone who’s employed or that means you don’t have your own boss, then you’re kind of stuck in the middle.
Speaker 1 (00:17:53):
And fortunately that’s not a large number. I believe it’s 10 or 15% of the population, but those are people that need to buy their own health insurance and that’s where a lot of the issues are, which is the health insurance expensive. It’s over a thousand dollars a month and then what are you getting for that insurance? So that’s kind of where it is in terms of the types of insurance and that between Medicare and Medicaid, everything in the middle is usually privately sold even. It could be even state funded, but it’s still privately sold. So that’s where we are in terms of the types of healthcare in the United States. So it’s not one big basket of health insurance offered by or mandated by the country, which is how most other countries are because most countries have a socialized medical care.
Speaker 1 (00:18:49):
We talked about eligibility for Medicare. Anyone aged 65 or whoever must have Medicare if you’ve been employed, you’ve paid into the system to support Medicare and Medicaid we talked about, which just tends to be for certain poverty levels and also patients that are with certain diseases or children. Now we get to the complicated stuff. So if you’re like a normal person that is either not employed or employed, but not over age 65, then you fall into all these private insurances and they call ’em HMOs, PPOs, IPAs, EPOs are all these terms. What do they mean and why does it matter? Let’s see. We have some questions coming up, so let me make sure I don’t miss those.
Speaker 1 (00:19:43):
Yes, my staff has been really good at answering your questions. They’re very well-versed in all of this stuff. A lot of what I’m telling you, my staff should be able to help answer for your specific situation. So if you want to for example, call the office and say, here’s my health insurance. What is my out-of-pocket cost for X, Y, and Z? We should be able to tell you that. All right, so here’s a question. I had a hernia Mesh repair and a post-op infection that resulted in an abscess that now has become a fistula. CT scan showed Mesh adhesions and the fistula at the resection point from my first hernia bowel resection, I’m in Canada. Any advice on how to find a good surgeon to fix this? Okay, so in Canada has a hybrid system similar to most social countries. So almost every socialist country has federally funded insurance, which has limitations.
Speaker 1 (00:20:45):
So because you are in a pot with everyone else, you need to get a line. If you’re dying, they’ll take care of you. If you have cancer, they should expedite your care. If you have a hernia, you’re kind of low on the totem pole unless you have an emergency and you get into, you end up in the emergency for a problem. So because there’s limited resources, limited number of doctors in the system, limited number of clinics that are funded by these programs, there’s also limited number of CAT scans and MRIs and so on. Then care tends to get rationed. And I use that term loosely. It’s not, it’s not really. Ration is just compared to the US system where you can go anywhere you want and get your ct, your MRI as long as you pay for it. That is not the case in most socialized countries.
Speaker 1 (00:21:37):
However, in someplace like Canada, there is also, you can also buy into a secondary market, which is a private market. And that because you’re adding extra payment can’t expedite your care. So in this situation, you have a problem, you have chronic problem. It’s not a life threatening problem, but it’s a chronic and very poor quality of life problem, which is a Mesh infection with an intestinal fistula going through it. You need very specialized care. You need the Mesh removed, the intestinal fistula repaired, that’s two maybe three operations, back to back reconstruction, infection control and so on. So you do have surgeons in Canada that are capable of doing this. There aren’t in every single province, number one. Number two, it’s very hard to penetrate your system in a lot of these places. They’ll see you and they’re happy to take care of you once you get into their system.
Speaker 1 (00:22:42):
I have had a handful of Canadian surgeons on a Hernia Talk and I’ll bring some more for you guys cause I do have great friends in Toronto and Ontario and Montreal. So your options are really infiltrate, really get to know your country’s healthcare system, infiltrate the system, figure out who the surgeon is that can help you. Somehow wiggle your way into getting to see them. And I think in Canada it has to go through your primary care doctor, which means your primary care doctor has to be very much your advocate to get you to care. From what I understand from patients of mine that have told me, it may or may not be true completely, but if you have a primary care doctor that is very much in invested, not financially invested, but invested personally invested into the healthcare system in Canada where they do not want to overtax the system that many of them I’ve seen have refused to order certain tests or refused to get patients to certain specialists, whereas that may have been in the best interest of the patient. So they have left that system and come to me for example. So in your situation with the intestinal fistula and the Mesh infection and sounds like at least one or two operations that you’ve had so far, you need to find a medical doctor that will be your advocate and then refer you to a specialty surgeon That will take on your case. Once you’re in the system, you should be able to get adequate care.
Speaker 1 (00:24:22):
Okay, there’s another question coming up. For people who’ve had postoperative complications like nerve damage, will insurance cover abdominal wall reconstruction? The answer is yes, it has to do with how it’s billed. So nerve damage or any complication from a surgery should be covered the same way that original surgery is covered. So if you have a hernia and you have a recurrence that should be covered. If you have a breast reconstruction for cancer and you have a complication from that, that should be covered as well because it was a cancer related problem. The problem is in this issue of nerve damage, which results in what’s called denervation. So if you have, you have a denervation abdominal wall, there’s you for every surgery we do, there’s a code. So we write a code. Anglo hernia has a code 4 95 0 5 is opening LA hernia pair.
Speaker 1 (00:25:26):
There’s no good code for denervation. The system is not perfect. And so if you don’t have a really good code and there and what you’re trying to do is to repair that denervation or that weakness by tightening up the muscle, the only code that you can use to tighten up the muscle is a tummy tuck code. And once you use that tummy tuck code, that automatically flags it as being cosmetic and therefore not approved by insurance. So you could have your doctor spend a lot of time and effort going through the process of explaining to the insurance company that this is not cosmetic. They’ll still say, well, the patient’s not going to die from this. It looks ugly because you’re bulging on one side. But that’s the way it is and we still consider it cosmetic, we will disapprove it. But if it’s really a complication of abdominal wall reconstruction, your surgeon can choose to call it a hernia even though there’s technically no whole. But from a functional standpoint and from a visual standpoint and from a mechanical standpoint, it is a hernia. So if you use a hernia repair code and a hernia repair process that is then therefore covered. So it’s the issue is the codes have not cut up with what we are doing in the abdominal reconstruction world. So I hope that’s helpful.
Speaker 1 (00:26:57):
Going back to those questions, so what are all these H M O, P P O, I P A, E P O, and by the way, when I say the insurance will cover it, it doesn’t mean they’re going to pay for all of it. It just means they’re not going to consider it cosmetic and therefore completely rejected. How much your insurance covers is very much dependent on your insurance, not necessarily on the operation itself. Let’s see, another question came up. Thank you for explanation. Okay, you’re welcome. You’re welcome. I try, okay, H M O, P P O, I P A, E P O, et cetera. So when you buy health insurance or you get into the health insurance market, that’s not Medicare, i e, you’re under 65, you’re into some type of public-private system. That private system can be costly or not so costly. And as with everything in life, you get what you pay for.
Speaker 1 (00:28:01):
So if you pay for very cheap insurance, you’re going to get very poor coverage. And by coverage I mean the out of pocket that you have to pay in addition to what you’re, so if you’re paying very little per month, which is called the premium, if you pay very little per month to have health insurance, if you do need care, it’s very likely that you’ll pay more out of pocket for that care. So let’s say you’re a 27 year old male and you’re paying the lowest amount for health insurance, and that varies depending on where you live. And then you get appendicitis. It’s very possible that your appendicitis surgery or your hernia surgery will be more expensive for you in terms of how much you have to pay out of pocket than someone who pays more for their insurance because that’s just the terms of your insurance. So when you get a bill, that bill, first of all, doesn’t matter who it comes from, you’re only allowed to bill one charge no matter what the person is situation is. So I’m just going to make up this number.
Speaker 1 (00:29:26):
You’re going to go to a hospital and everyone that comes to the hospital that gets, let’s say abdominal abdominal reconstruction, the hospital will charge the insurance, they’ll, you will get a bill for a hundred thousand dollars. Now no one’s going to pay a hundred thousand dollars for a hernia repair, but the hospital’s only allowed to pick one number for hernia repairs and they’re going to choose a hundred thousand dollars. Why? Because there may be some guy that’s going to show up one day that has really good insurance and the insurance will pay a hundred thousand dollars because insurance will pay whatever is built. But most of the time the insurance will say, yeah, that’s really nice, but we don’t agree to that. In fact, we have a contract, you may remember that we signed last year, that when our patients come to you and they need a hernia repair, you’re only going to charge us $15,000 or $10,000. That’s or 5,000 whatever depends on the code. So we’re going to go by our contract, which means the hospital writes off 95,000 or 90,000 or 80,000, whatever that number is, the difference. So first the question is, is there a contract, how much it’s going to cost for that care?
Speaker 1 (00:30:54):
And that contract with hospitals is usually a very well negotiated contract. My hospital’s very good at negotiating those contracts, contracts and everyone knows that they all want to come to my hospital for care. So the insurance companies are willing to negotiate because they want to keep their customers happy because if they tell half of Calif, half of Los Angeles that they can’t go to this top hospital, they’re going to get pissed off and they will sign up for that type of health insurance. So that’s actually happened before I think Blue Shield or something decided they won’t cover. I forget, don’t quote me exactly. There’s one hospital that decide they’re not going to cover deliveries of births at Cedar Sinai. Cedar Sinai is like the top place to get your baby delivered in Los Angeles, more in the top in the nation. We do one of the most and everyone wants to get their baby delivered at Cedar Sinai.
Speaker 1 (00:31:56):
Michael Jackson delivered, Madonna delivered. Everyone can think of delivered their babies here. So if you have insurance that says, yeah, we don’t cover Cedars for births, that’s not going to fly. And so there’s some leverage there. So if you give really good care as a hospital and you have the favor of the patients, the patients have the power and the patients will say, I’m going to pick the insurance company that where my GYN or OB will be able to take care of me and my pregnancy for example. So there’s a little bit of negotiations there. Now, the negotiations between the insurance company and the doctors, that’s a very different discussion. First of all, there’s almost no discussion. So insurance and say, this is how much we’re going to pay you take it or leave it. Because doctors tend not to unionize, they tend not to work together.
Speaker 1 (00:32:53):
Whereas hospitals are like big negotiating power. Doctors do not. So there’s this whole issue of in-network, out of network, back in the eighties insurance company or seventies or eighties, I think eighties, the insurance companies came out with this network and the whole issue was we only want doctors that give the best care for our patients. So if you were as being an A network doctor for health insurance, that was actually a good thing. It meant that you were already vetted, you were like academic or providing excellent care. The mathematics behind insurance companies totally changed. So now in network, doctors unfortunately are getting screwed. So in-network does not mean you’re getting the best care. It means you’re getting the cheapest care. So if you are an in-network doctor, you are agreeing to get paid whatever that health insurance believes you should get paid. Usually it’s very little, $10, $20, $30, $40, rarely more than a hundred dollars depending on the level of care.
Speaker 1 (00:34:08):
But you’re hoping that by being in their network, when a patient goes online to see what doctor they can see in their network, your name will pop up. And so you’re automatically being fed patients from a directory from the insurance company. So higher volume, lower reimbursement per patient. That’s kind of volume based practice understanding that you also have to play a game with these insurance companies. If you’re a great doctor and you’re saying, oh, let’s figure out what’s wrong with you, let’s get a CAT scan, let’s draw some blood, let’s check a urine culture. You may be at risk, or you know what, you need a specialist. Let me send you to this gastroenterologist. I think it’s from your GI system. Or let’s go see a urologist. Maybe you have a kidney stone, you may be as a doctor, you may get tagged by your insurance company contract as being too expensive in the care that you provide.
Speaker 1 (00:35:12):
They actually have a report, they know everything about us and says like Doctor A per patient spends $20 in resources, never refers to anyone, barely gets a mammogram on their patient or blood tests. And Dr. B spends $2,000 per patient constantly ordering blood tests and CT scans referring to specialists and referring to out of network specialists and so on. So you are tagged and you get a letter. I’ve seen this of my friends who have been in network saying, good job, but you offer really expensive care and we really would prefer that you’d be a little bit more judicious about which labs you use and what amount of labs that you order and which doctors you send to and so on. Because continue doing this type of practice, we may have to take you out of our network. So the doctors freak out like, oh shoot, if I’m out of network, then who’s going to come see me? I’m getting all my referrals from the insurance company.
Speaker 1 (00:36:26):
And some doctors may say, you know what? I’m a doctor. I do what’s best for my patients. If I don’t agree with being bullied by you, the health insurance company, some doctors may be like, shoot, I have a family and children and I can’t be dropped from this insurance company because the volume of patients that are referred to me will dramatically reduce, which means my income will reduce and so on. So it’s a little bit of a problem. So when people say, are you in network or out of network? I am out of network. I do not believe that I should work based on the demands of a health insurance company. Health insurance companies are not interested in quality of care. They’re interested in how much it pays to be their patient. So how expensive of a care do I provide? And I’m sorry, I’m not going to spend five to 10 minutes per patients.
Speaker 1 (00:37:24):
So I can see 40 patients in one day in network because all my patients are complicated. My patients need an hour at least for me to review. I call them, I emailed them. I’m constantly in communication with them. I have them send me more information. My office is on the phone getting records and imaging and we get back to them. I have a full-time nurse that’s a hundred percent available to you. That kind of care cannot be performed in an in-network situation because you can’t get paid $20 to spend over an hour with a patient. So I am what’s called out of network, which means I determine how much I charge and not the insurance company and I don’t base my decision to see you, my decision to care for you based on any demands from the insurance company. And no insurance company can tell me what to do.
Speaker 1 (00:38:24):
It’s also why I’m in private practice because I don’t want a hospital administrator to tell me what to do either. But that’s pretty much it. So no, I do not. I am out of network with all these insurance comp companies. So PPOs or private healthcare insurances are the only insurances that even have an in-network out of network. So we are considered out of network. What does that mean? Come see me. I will bill your insurance but do not expect to pay a low amount. Your reimbursement from the insurance will be lower and your out-of-pocket will be higher. There are other private insurances like E P O or HMO. They’re basically the same. They only have one network. You’re either in or you’re completely out in which I am invisible to them. You might as well not have insurance. And so for all of you that are at a HMO or E P O or other exclusive limited insurance systems, I’m invisible to them. They don’t know who I am and I cannot bill them because I’m not considered a provider at all. And so with those, we provide you a discounted cash rate. Medicare is the same.
Speaker 1 (00:39:48):
There’s no negotiations with Medicare. They have a publicly determined predetermined rate at which they pay. It also comes with a lot of regulations in addition to getting that payment. So similar to the other limited provider systems like H M O and E P O with Medicare and Medicaid, which are both public systems. I am not a provider. They don’t know who I am. I’m not on their list in anywhere. So it’s not like an in-network out of network. I’m just don’t belong to any network. So those as well, my office provides a discounted cash rate for you. So that’s been how I handle it because my practice is so, it’s demanding, it’s very time demanding and I really enjoy, I actually enjoy spending the time with you guys and figuring these things out. I understand that not everyone can see me, but that’s way around my practice.
Speaker 1 (00:40:50):
Now there’s plenty of colleagues of mine, many of those who are here on hernia talk as guests of mine that are employed surgeons or employed doctors. If you are employed in many ways you are protected from all this stuff that I have to deal with. So they don’t deal necessarily with the business of the practice. However, they often do not have the time to afford to these very complex situations. So I have friends that have similar practice of mine, but they’re part of a university practice. They’re employed, they have a salary, there’s virtually no incentivization for them to see a 10 minute patient versus a one hour patient. And based on their volume, they’re encouraged to see that 10 minute patient and discouraged from seeing the one hour patient. Now many of them like doing it and so they work against the system to do so, but it’s a little bit of a problem.
Speaker 1 (00:41:54):
And so many of those who call the office and they say, we’ll see you eight months from now and surgery will be six months, 10 months after that because they are turning in a volume-based practice. And I used to be a high volume practice and I’ve slowly moved away from it. I’m much happier with that. So I do want to make this point though, and I think that this is what, so correct the question answer I, I’m not a provider at Medicare and Medicaid and I’m an out of network provider for UnitedHealthcare. What does that mean? I get a lot of people say, I can’t see you, you don’t accept my insurance actually like UnitedHealthcare, I do accept your insurance.
Speaker 1 (00:42:48):
I’m just concerned out of your network. So that means the reimbursement rate is lower for you now, which is weird to me because people who have private health insurance and have out of network benefits are paying more for that health insurance. You would think that the privilege of paying more for that health insurance should include the privilege of being able to see out of network providers. It’s just a weird system. I hate it. It’s just a weird system. Sometimes I feel that you should just get the most simple insurance and just pay cash for the rest of it because it’s so ridiculous how insurance companies charge you extra for the privilege of seeing out of network providers and then they don’t cover the services because you have to pay extra for that too. It just makes no sense to me. But my point is this, do not feel that you cannot get care because you have bad insurance.
Speaker 1 (00:43:51):
First of all, let’s say you have the worst insurance and Medicaid really is the worst insurance. It has the least number of providers available, the least number of specialists available, the longest waiting period. And it’s really helpful only for emergency surgery. It’s really hard to find a Medicaid provider that for elective or primary care services, let’s say you have Medicaid, lowest possible, that’s when you can’t get care. You just have to pay cash for it. And the clincher is if you have the cash to pay for your healthcare, then you probably are not eligible for Medicaid. But let’s say maybe that’s a bad example. Maybe you have a HMO insurance. So something that is very limited network, but it’s cheap.
Speaker 1 (00:44:40):
You’ll have a list of doctors, you can see whether they’re primary care or specialists. Specialists will be very limited. But you independent person, you, is it a free country? You can see whatever doctor you want, it’s just going to cost you. So people in the United States, sometimes I feel forget that paying for healthcare outside of your health insurance is available. You I can go get a COVID test right now or I can stay in line and get a COVID test. It all depends on whether I want to kind of do it like at an office next door or stay in line for four hours. It all depends on how much you’re willing to care to pay and how important it is to you. So if you have a limited network insurance or you don’t have out of network benefits, it doesn’t mean you can’t see a doctor that’s out of network. But you will have to save money and seek that care. And in my experience, people who have chosen to see non-specialist for something that really a specialist should handle. So I’m not saying every hernia should be done by a specialist. It would be nice. I have a lot of patients that see me that have a very simple, straightforward hernia and they have excellent outcome. And in general, those of us who are specialists will provide you with better surgical outcome than those that are not specials. That’s just a fact. So I’m not making that up.
Speaker 1 (00:46:18):
However, if you have an infection, Mesh infection, chronic pain, nerve issue, Mesh erosion, recurrent hernias, abdominal wall, that’s very abnormal, rare hernias, those really should be done by a specialist. And if you’re able to find a specialist and you can save the money to see them, by all means, take advantage of that and do spend that money on your healthcare. I cannot stress how important it is to invest in your health. I see so many patients that, and I’m not trying to say this in a very potty way, it really isn’t. But we just see it so often where they choose not to see me purely on financial reasons and purely on financial reasons. And I’m not saying they couldn’t afford it, they chose not to afford it. They go and have their surgery elsewhere and I get a phone call afterwards, complication should never have done this, should have followed your advice, should have just saved the money and come to see you or something that nature.
Speaker 1 (00:47:30):
But guess what? Now you have a more complicated operation, more complicated situation. You’ve wasted money with the last operation you did and you lost time off from work. All those add up and now you need a third H hernia repair, operational redo and so on. Whereas all that could have been handled with one operation, one leave from work, one recur recovery time and you’ve been one and done and could move forward to move on. So it helps to go to a specialist, especially if it’s not your first time need surgery. I highly, highly, highly recommend it. There’s many of us around the country that can provide this to you. We care. We love hernias. We eat and breathe it. I’m here every week talking about it. I mean, this is stuff that I really enjoy and I have a handful of friends all around the nation that do this for a living.
Speaker 1 (00:48:21):
So do save the money and invest. I can’t tell me how many people say I can’t because I save money for a vacation or they just bought a new car or other things that are ephemeral. It’ll be gone within days to two years. Those things will be gone, but your health is forever. So at the very least, get some information by a specialist. Invest in that. See? See what I think Once you understand the beauty of being taken care of by a specialist and how different that is, then going to a general doctor that’s not a specialist. If you have a special specialty need, then you’ll understand how worth it that investment is. And I hope that that’s really helpful.
Speaker 1 (00:49:19):
That was intense. I don’t know how to explain this without sounding, I don’t like to talk about money. So I don’t know how to explain this without sounding bad, but I feel like a lot of patients make the wrong decisions and I just feel bad about it. Okay, question. Does capitation still exist or other health insurance plans in which primary provider is at risk for delivering comprehensive care? Okay, good question. So there are a lot of good things that have been passed since the passage of the Affordable Care Act. One of those is more, are we getting calls? One of those is there is no lifetime limit. So there used to be you can’t spend more than a million dollars or something. And sometimes people had a kid and the kid was born with some congenital defect and that 1 million was gone the first three days of their life.
Speaker 1 (00:50:18):
So it got rid of the lifetime cap as to how much insurance will cover. It also got rid of some other factors like preexisting conditions which prevented people from getting the care they needed. And so those are all really good things. In terms of capitation, no, there is no capitation in the US insurance plans that has all gotten rid of, which is why it’s so important to keep the Affordable Care Act going because a lot of the elements of it, a lot of the elements of it have really helped people get care. And let me tell you this, another thing that the Affordable Care Act did, I think if I’m not mistaken, it it did prevent health insurance companies from having more than a 20% profit level to the point where if they are profiting more than 20%, they have to pay you back. So many of you may have gotten checks from your health insurance company because guess what, they’re still making more than 20% profit.
Speaker 1 (00:51:25):
So regardless of how much these insurance bills are trying to divert care and prevent what they consider expensive care to be provided, and I’m always on the phone trying to get approval for an MRI or an injection or something like that. They’re making a lot of profit question. I didn’t even know there were hernia specialists when I had my initial surgery. Now it’s been two years that I’m disabled since a general surgeon messed me up. Yeah, yeah. It’s obviously every surgery HA is at risk for complications. We all have complications too as experts, but the risk of it is usually lower. And I need surgery myself and I thought it would be a straightforward operation, but I still went and got a second opinion from another expert in town before I commit to surgery. So even though I knew the situation, I knew exactly what need to be done. So it’s always good to get second opinions regardless of what surgery you undergo and then make the decision. And if you need a second surgery, then for sure only go to a hernia specialist for that. Let’s see. More questions before we’re almost done. That was very fast. So what are in-network out of network plans? We already discussed it in-network and out of network really has to do with how much the insurance is willing to take pay for the costs and really how much your out of pocket will be. Just because a surgeon or doctor is out of network does not mean you can’t see them. You just have to pay more out of pocket usually.
Speaker 1 (00:53:16):
And oh, I get this question a lot. What’s the best insurance or something else they say is, doctor, oh don’t worry. I have the best insurance. I’m like, first of all, there is no best insurance. Best insurance means I tell ’em how much they cost and they’ll pay me. That’s not going to happen. No insurance does that or it means that you’re paying a lot and you don’t have to pay anymore out of pocket. Also no insurance does that. So there is no best insurance. The most expensive insurance is also not the best insurance and it’s just a sucky system. I don’t know how best to explain it. No one likes health insurance. They’re, they’re all there to make profit. They’re obstructive to normal patient care. And I hate dealing with insurance companies and I almost feel like the way that they treat patients and the way that they treat the doctors is on purpose to get the patients to start being mean or hate the doctors or somehow feel like the doctor’s the one that’s doing wrong.
Speaker 1 (00:54:30):
And that’s just unfair. I’ll give you an example. So I think it’s a federal mandate that all COVID testing be free. So you can’t charge for COVID testing. And at least in California, I know that the insurances, like I believe it’s Blue Shield, blue Cross Blue Shield of California has also agreed that they will pay, and I think it may be a state mandate that the ins, if you have insurance, your insurance will have to pay for your COVID testing and they can’t argue over it over how much they pay. They will have to pay whatever the contractor rate is. And if there’s no contract with out of network lab, then they will have to pay whatever the published, whatever the published cash rate is for the COVID test. So I have friends that have kids that need to get COVID tested because there’s no vaccination.
Speaker 1 (00:55:40):
They want to go to schools, they get COVID test. I think once or twice a week they all go to this local lab, gives ’em great service, the whole school goes there and they’re getting these enormous bills and they’re freaking out. So now they’re pissed off at the COVID lab tester, why are you billing us? This is horrible. We’re not supposed to be billed. This is supposed to be paid for. Well guess what? The health insurance is the one that should be pissed off at because the health insurance has decided to deny that bill for stupid reasons, use the wrong code. We couldn’t read the code, whatever. So because the health insurance company is delaying payment, which means they’re holding onto their own money, they’re delaying payment, it’s looking as if that bill is now needs to be paid by the patient. So the patient gets pissed off at the lab, sending them a bill saying this is the invoice.
Speaker 1 (00:56:46):
But if you look at how much the health insurance paid, it’s not, it’s like blank because they haven’t paid yet. So this is kind of where all this mistrust and anger comes about. You have a bunch of parents that are angry because they’re getting these big bills, which they don’t have to pay by the way. The lab company is saying, listen, that’s just like normal billing practices. You don’t have to pay this. We’re just waiting for the insurance to pay it. But they’re dragging their fee. It’s been two months, three months, six months. So you’re just being told that nothing has been paid yet by the insurance company. Don’t get mad at us. We don’t expect money from, you get mad at your health insurance for not paying yet. And then it becomes this nefarious relationship now between the lab and the parents. And then they really need to get their anger against the health insurance. But health insurance like, hey, serves you right for going to out of network lab and it’s just not fair and I don’t like it. It’s just to explain to you how complicated these things can get. And it’s just so horrible.
Speaker 1 (00:57:58):
Which is why I hate this game that the insurance is paid. Which is why in my practice, in my practice, we say ignore all billing because the insurance company will send you a bill, which they say is not a bill. This is not a bill. But guess what? Patients don’t read that. They see like this big number, you oh, this much money. I’m like, ignore all of that. We will n in our practice, my practice, you will never get billed after your care. We will tell you how much you’ll be upfront and then we’ll deal with it with the insurance afterwards. And if we get paid, great. If we can help us get paid, that’s great, but we just don’t want you and us and the insurance to get into a tiff because the insurance is a really good at playing that game. So I hate to be so negative. I’m usually a very positive person, but I hate dealing with insurance companies because they play a nasty, nasty game. They are a nasty people.
Speaker 1 (00:59:00):
Medicare supplemental insurance. We didn’t talk about that real quick. That is something interesting. So Medicare by law will pay for 80% of the contracted rate and the other 20% the patient has to pay in cases where the patient cannot afford to pay, then there’s Medicaid that can pay that 20% in patient. In cases where the patient can pay, either pay a cash or you buy insurance to pay your 20%. So usually 20% is not a big deal. But if you have cancer or need a major surgery, that 20% can be a big deal, which is why you have supplemental insurance. But supplemental insurance is different from Medicare in one way in that it provides that 20% out of pocket. But what it doesn’t do is it doesn’t cover anything that Medicare doesn’t cover. So as an example, I am not a Medicare provider. I can’t, can’t bill Medicare.
Speaker 1 (01:00:02):
So we give you a cash rate. So let’s say you have Medicare and the Medicare supplemental insurance. That supplemental insurance also will not, I can’t be provided for that either because it’s linked to the Medicare, but all health insurance, which is great. By the way, do most health insurances restrict you to in-network providers or require an unreasonably high premium for out-of-network providers? That’s very well put. That’s exactly what I was trying to get at is it’s either a very restrictive health insurance HMO or E P O where they restrict you only to in-network providers and will provide no reimbursement and no coverage for any care provided by an out-of-network provider. Or you can pay a huge amount of money for a higher premium for the privilege of being able to be seen by an out-of-network provider.
Speaker 1 (01:00:58):
And then you still have to pay more, which makes no sense to me. Is it not then the quality of the healthcare that you practically that you get the healthcare you get practically determined by the insurance you choose? Partially yes. Partially yes. However, in the United States, you can go outside of your healthcare insurance and you can go outside of your network and you don’t need to use your health insurance. So yes, it’s incumbent on you as a patient to be your own best advocate. And I’m going to leave you with this. You need to be your own best advocate. And you can petition your health insurance because they’ll listen to you, not to the providers because you’re the one paying the bills to them. You can petition the pro, make life health for the healthcare, for the healthcare, for the health insurances, to petition them.
Speaker 1 (01:01:49):
You can choose to take your healthcare under your own wings, reign it in and see whoever you want to see. And you may have to pay extra out of pocket or cash and you should save money and have a pocket of money for these type of situations so that you don’t get 2, 3, 5, 9 operations when you can get one or maybe two operations with a, because in the long run you will be saving money and improving your quality of life and having a much better recovery and less ability to, what do you call it, have a good recovery and actually work or be with your family. So on that note, I will leave you. It’s been a fantastic hour. I hate talking about insurance, but I actually know fairly a lot about it. So it really hurts me when people call on, I get, oh, you don’t take my insurance, therefore I cannot see you.
Speaker 1 (01:02:55):
No, not therefore you can see me. Whatever you want. You just would want. Or it’s not just me, any hernia specialist, it’s a free country. You can choose to see us, whatever, however you want want, but it’s not free. And depending on your health insurance, it may cost you more or less out of pocket. And one thing we didn’t talk about is cash. Almost every situation you’re in can be solved with asking for a cash rate, which is almost always lower than the rate that is billed to insurances. And on that note, please don’t have me talk about insurance anymore. It really doesn’t. I don’t enjoy it. Thanks everyone. See you.