What You Need to Know About Health Insurance Part 6

Note: This is Part 6 of an 8 part series that is also being published in the Chester County Press.

“Their Secret Provider Agreement”

When it comes to accessing healthcare, we face two very separate realities. The first is the one Congress and the healthcare insurance industry promote, which is that we don’t ration healthcare in the United States. The other is the one the Supreme Court has acknowledged where rationing is the “very point” of our managed-care healthcare insurance system.

 Which raises the question of how can we have two realities for something so personal and public? How can our healthcare plans enforce rationing when common sense and the law tell us that only our doctor can determine the care we need and are promised?

 They do it by establishing secret contracts (Provider Agreements) with every in-network doctor, hospital, and other healthcare provider within their network of approved healthcare providers and services — contracts that define every element of a provider’s operation within the network — contracts that restrict the right to coverage and payment — and contracts that severely limit the ability of our doctor to serve us. But, most important, these are contracts that cannot be found in any information or source available to you or me. Contracts that are locked away from the public and never explained or even acknowledged. But, contracts that I have seen and studied at length.

 As with most contracts, the design is more important than its terms and conditions, and that’s certainly true here. Because these contracts (Provider Agreements) only allow an in-network provider (doctor, hospital, or other form of healthcare provider) to get paid if they comply with the decisions of your plan. That’s right, these Agreements literally bar a provider from billing you anytime they provide care your plan has refused to approve.  So they don’t actually deny the care our doctor is prescribing. They simply say the provider can’t bill anyone for it. HOWEVER, and this is a very big however, these Agreements require the provider to supply the care OUR doctor is prescribing so long as it’s prescribed as necessary health care.

The bottom line is that your plan is counting on you mistaking a denial of coverage and payment with a loss of the right to the care your doctor believes you need. Quite to the contrary. These Agreements make it absolutely clear that we are owed the care, but the provider is contractually required to provide it for free – free as in the provider isn’t allowed to bill us. Which opens the door for our next article.

See Other Articles in the Series