Re: UHC Out-of-network provider

[Guest guest]

I have encouraged several patients in the Bethesda, land region who were

told that my charges were above usual and customary to call 20-30 PT practices

in the area to see what their charges are. ABout 25 percent were cheaper, most

were in the same range and about 25% were much higher. Interestingly, the more

expense practices were either hospital- or physician-owned. The concept of R & C

is pure nonsense. A few of these patients managed to get paid after presenting

the data; others did not get anywhere.

Jan

Jan Dommerholt, PT, DPT, MPS, DAAPM

Bethesda Physiocare®, Inc.

7830 Old town Road, Suite C-15

Bethesda, MD 20814-2440

United States

+ (voice)

+ (fax)

dommerholt@...

www.bethesdaphysiocare.com

Anne Arundel Physiocare®

127 Lubrano Dr, Suite L-3

polis, MD 21401-7322

+ (voice)

Myopain Seminars, LLC

+ (voice)

+ (fax)

www.myopainseminars.com

dommerholt@...

http://www.linkedin.com/in/jandommerholt

> IMPORTANT NOTICE

> This message is intended only for the use of the individual or entity to which

it is addressed and may contain information that is privileged, confidential and

exempt from disclosure under applicable law. If you have received this message

in error, you are hereby notified that we do not consent to any reading,

dissemination, distribution, or copying of this message. If you have received

this communication in error, please accept our apologies. notify the sender

immediately and destroy the transmitted information.

>

> Thank you.

>

> Bethesda Physiocare®

>

[Guest guest]

Great point, Matt -

" Reasonable (from the payor's perspective) and customary (from the payor's

perspective) " is a good way to view those things. Sort of like when an

insuror or governmental agency says " You'll get all the necessary medical

care you need -- as determined by an accountant in our home office. "

Dr. Dick Hillyer, PT,DPT,MBA,MSM

_____

From: PTManager [mailto:PTManager ] On Behalf

Of

Sent: Thursday, March 17, 2011 8:00 PM

To: PTManager

Subject: Re: UHC Out-of-network provider

Matt,

The truth is that " reasonable and customary " is, at least at times, a myth.

Many years ago, after the birth of our first child, we found our insurer

would pay only a fraction of the bill based on their R & C. I pursued the

issue of how R & C was established (both geographically and statistically)

which took many phone calls and many unproductive conversations before

finding someone who was willing to give me that facts. For that particular

insurance, I found that they based their R & C on a county basis in NJ and on

the mean of the charges. I subsequently called all two dozen ob/gyn

practitioners that I could find in the county and found that ALL of them

charged significantly ABOVE R & C, thereby rendering the insurance company's

so-called R & C a pure fabrication. I called back the insurance company and

with a little leveraging involving threat of legal action and the

involvement of the NJ insurance commission (which actually had some teeth as

compared to Michigan's useless commission), I got paid the full amount. The

problem with so many of these issues is that collectively, physical

therapists are willing to bend over and say " Please sir, may I have

another " , and that's exactly what we get.

, PT, OCS

Marquette, MI

UHC Out-of-network provider

For those of you who are non-participating providers with United Health Care

(UHC) what is your usual and customary reimbursement from UHC? It is

approximately $160/visit for me in Baltimore, MD.

Sumesh , PT

Baltimore, MD

[Guest guest]

Great point, Matt -

" Reasonable (from the payor's perspective) and customary (from the payor's

perspective) " is a good way to view those things. Sort of like when an

insuror or governmental agency says " You'll get all the necessary medical

care you need -- as determined by an accountant in our home office. "

Dr. Dick Hillyer, PT,DPT,MBA,MSM

_____

From: PTManager [mailto:PTManager ] On Behalf

Of

Sent: Thursday, March 17, 2011 8:00 PM

To: PTManager

Subject: Re: UHC Out-of-network provider

Matt,

The truth is that " reasonable and customary " is, at least at times, a myth.

Many years ago, after the birth of our first child, we found our insurer

would pay only a fraction of the bill based on their R & C. I pursued the

issue of how R & C was established (both geographically and statistically)

which took many phone calls and many unproductive conversations before

finding someone who was willing to give me that facts. For that particular

insurance, I found that they based their R & C on a county basis in NJ and on

the mean of the charges. I subsequently called all two dozen ob/gyn

practitioners that I could find in the county and found that ALL of them

charged significantly ABOVE R & C, thereby rendering the insurance company's

so-called R & C a pure fabrication. I called back the insurance company and

with a little leveraging involving threat of legal action and the

involvement of the NJ insurance commission (which actually had some teeth as

compared to Michigan's useless commission), I got paid the full amount. The

problem with so many of these issues is that collectively, physical

therapists are willing to bend over and say " Please sir, may I have

another " , and that's exactly what we get.

, PT, OCS

Marquette, MI

UHC Out-of-network provider

For those of you who are non-participating providers with United Health Care

(UHC) what is your usual and customary reimbursement from UHC? It is

approximately $160/visit for me in Baltimore, MD.

Sumesh , PT

Baltimore, MD

[Guest guest]

I totally agree that U & C fees are arbitrary and have little, if any, basis in

true data. When I was selling group insurance and a potential client would ask

how we derived U & C I would always say, " I will have to have actuarial call you

on that " .

A simple google search will yield many cases of the AMA bringing suit against

Aetna, UnitedHealtcare, etc for manipulation of U & C fees. I really don't know

if the APTA has ever done the same.

Matt Capo, PT

Accelerated Physical Therapy and Occupational Health, Inc.

Bay St. Louis and Diamondhead, Mississippi

Re: UHC Out-of-network provider

I have encouraged several patients in the Bethesda, land region who were

told that my charges were above usual and customary to call 20-30 PT practices

in the area to see what their charges are. ABout 25 percent were cheaper, most

were in the same range and about 25% were much higher. Interestingly, the more

expense practices were either hospital- or physician-owned. The concept of R & C

is pure nonsense. A few of these patients managed to get paid after presenting

the data; others did not get anywhere.

Jan

Jan Dommerholt, PT, DPT, MPS, DAAPM

Bethesda Physiocare®, Inc.

7830 Old town Road, Suite C-15

Bethesda, MD 20814-2440

United States

+ (voice)

+ (fax)

dommerholt@...

www.bethesdaphysiocare.com

Anne Arundel Physiocare®

127 Lubrano Dr, Suite L-3

polis, MD 21401-7322

+ (voice)

Myopain Seminars, LLC

+ (voice)

+ (fax)

www.myopainseminars.com

dommerholt@...

http://www.linkedin.com/in/jandommerholt

> IMPORTANT NOTICE

> This message is intended only for the use of the individual or entity to which

it is addressed and may contain information that is privileged, confidential and

exempt from disclosure under applicable law. If you have received this message

in error, you are hereby notified that we do not consent to any reading,

dissemination, distribution, or copying of this message. If you have received

this communication in error, please accept our apologies. notify the sender

immediately and destroy the transmitted information.

>

> Thank you.

>

> Bethesda Physiocare®

>

[Guest guest]

" Pricing " has been duly called the " magical language of economy. " That is

dead-on true, but pricing is a virtuous language only when clear and accurate of

course, and it is clear and accurate ONLY in direct consumer-producer

interactions, i.e. only when direct consumer-producer interaction determines

need and value.

We have meddled dramatically with healthcare consumer-producer relationships by

injecting powerful forces between individuals and providers. That terrible

mistake has created endless opportunities for manipulation---power grabbing and

money grabbing. Needless to say the mischief is not all on the payer side, as

demonstrated by chronic increases in provider charges that for decades have

out-paced inflation, and utilization promotion focused almost exclusively on

treatment while virtually ignoring prevention. Patients themselves are also not

without guilt, for given an inch the average Joe is soon likely to demand a

mile.

Once the pandering promise was made that medical services and products would be

" covered " it was just a matter of time before cleverness, greed, and fear worked

to make the system ridiculously expensive, cumbersome, and most importantly,

utterly disconnected from the true wants and needs of individuals. That is where

we are today, with many, many groups of all stripes and sizes battling for the

right to tell individuals what they will do, how they will do it, and how much

they will pay for it.

The problem therefore is not insurance companies per se, but the system we

invented that has given insurance companies (and government, and providers, and

everyone else with a stake in the situation) a system-sized weapon to be wielded

in the fight for a bigger piece of the pie. Given all the possibilities for

shenanigans, it is no surprise that insurance coverage and rate-setting and

value analysis and all the rest are radically dysfunctional, and that

communication about such things is often marked by euphemism or even outright

lies.

One of my favorite quotes, modified with apologies to :

" Complexity is the refuge of scoundrels. "

Dave Milano, PT, Rehabilitation Director

Laurel Health System

________________________________

From: PTManager [mailto:PTManager ] On Behalf Of

acceleratedptbsl@...

Sent: Friday, March 18, 2011 10:38 AM

To: PTManager

Subject: Re: UHC Out-of-network provider

I totally agree that U & C fees are arbitrary and have little, if any, basis in

true data. When I was selling group insurance and a potential client would ask

how we derived U & C I would always say, " I will have to have actuarial call you

on that " .

A simple google search will yield many cases of the AMA bringing suit against

Aetna, UnitedHealtcare, etc for manipulation of U & C fees. I really don't know if

the APTA has ever done the same.

Matt Capo, PT

Accelerated Physical Therapy and Occupational Health, Inc.

Bay St. Louis and Diamondhead, Mississippi

Re: UHC Out-of-network provider

I have encouraged several patients in the Bethesda, land region who were

told that my charges were above usual and customary to call 20-30 PT practices

in the area to see what their charges are. ABout 25 percent were cheaper, most

were in the same range and about 25% were much higher. Interestingly, the more

expense practices were either hospital- or physician-owned. The concept of R & C

is pure nonsense. A few of these patients managed to get paid after presenting

the data; others did not get anywhere.

Jan

Jan Dommerholt, PT, DPT, MPS, DAAPM

Bethesda Physiocare®, Inc.

7830 Old town Road, Suite C-15

Bethesda, MD 20814-2440

United States

+ (voice)

+ (fax)

dommerholt@...<mailto:dommerholt%40bethesdaphysiocare.com>

www.bethesdaphysiocare.com

Anne Arundel Physiocare®

127 Lubrano Dr, Suite L-3

polis, MD 21401-7322

+ (voice)

Myopain Seminars, LLC

+ (voice)

+ (fax)

www.myopainseminars.com

dommerholt@...<mailto:dommerholt%40myopainseminars.com>

http://www.linkedin.com/in/jandommerholt

> IMPORTANT NOTICE

> This message is intended only for the use of the individual or entity to which

it is addressed and may contain information that is privileged, confidential and

exempt from disclosure under applicable law. If you have received this message

in error, you are hereby notified that we do not consent to any reading,

dissemination, distribution, or copying of this message. If you have received

this communication in error, please accept our apologies. notify the sender

immediately and destroy the transmitted information.

>

> Thank you.

>

> Bethesda Physiocare®

>

[Guest guest]

" Pricing " has been duly called the " magical language of economy. " That is

dead-on true, but pricing is a virtuous language only when clear and accurate of

course, and it is clear and accurate ONLY in direct consumer-producer

interactions, i.e. only when direct consumer-producer interaction determines

need and value.

We have meddled dramatically with healthcare consumer-producer relationships by

injecting powerful forces between individuals and providers. That terrible

mistake has created endless opportunities for manipulation---power grabbing and

money grabbing. Needless to say the mischief is not all on the payer side, as

demonstrated by chronic increases in provider charges that for decades have

out-paced inflation, and utilization promotion focused almost exclusively on

treatment while virtually ignoring prevention. Patients themselves are also not

without guilt, for given an inch the average Joe is soon likely to demand a

mile.

Once the pandering promise was made that medical services and products would be

" covered " it was just a matter of time before cleverness, greed, and fear worked

to make the system ridiculously expensive, cumbersome, and most importantly,

utterly disconnected from the true wants and needs of individuals. That is where

we are today, with many, many groups of all stripes and sizes battling for the

right to tell individuals what they will do, how they will do it, and how much

they will pay for it.

The problem therefore is not insurance companies per se, but the system we

invented that has given insurance companies (and government, and providers, and

everyone else with a stake in the situation) a system-sized weapon to be wielded

in the fight for a bigger piece of the pie. Given all the possibilities for

shenanigans, it is no surprise that insurance coverage and rate-setting and

value analysis and all the rest are radically dysfunctional, and that

communication about such things is often marked by euphemism or even outright

lies.

One of my favorite quotes, modified with apologies to :

" Complexity is the refuge of scoundrels. "

Dave Milano, PT, Rehabilitation Director

Laurel Health System

________________________________

From: PTManager [mailto:PTManager ] On Behalf Of

acceleratedptbsl@...

Sent: Friday, March 18, 2011 10:38 AM

To: PTManager

Subject: Re: UHC Out-of-network provider

I totally agree that U & C fees are arbitrary and have little, if any, basis in

true data. When I was selling group insurance and a potential client would ask

how we derived U & C I would always say, " I will have to have actuarial call you

on that " .

A simple google search will yield many cases of the AMA bringing suit against

Aetna, UnitedHealtcare, etc for manipulation of U & C fees. I really don't know if

the APTA has ever done the same.

Matt Capo, PT

Accelerated Physical Therapy and Occupational Health, Inc.

Bay St. Louis and Diamondhead, Mississippi

Re: UHC Out-of-network provider

I have encouraged several patients in the Bethesda, land region who were

told that my charges were above usual and customary to call 20-30 PT practices

in the area to see what their charges are. ABout 25 percent were cheaper, most

were in the same range and about 25% were much higher. Interestingly, the more

expense practices were either hospital- or physician-owned. The concept of R & C

is pure nonsense. A few of these patients managed to get paid after presenting

the data; others did not get anywhere.

Jan

Jan Dommerholt, PT, DPT, MPS, DAAPM

Bethesda Physiocare®, Inc.

7830 Old town Road, Suite C-15

Bethesda, MD 20814-2440

United States

+ (voice)

+ (fax)

dommerholt@...<mailto:dommerholt%40bethesdaphysiocare.com>

www.bethesdaphysiocare.com

Anne Arundel Physiocare®

127 Lubrano Dr, Suite L-3

polis, MD 21401-7322

+ (voice)

Myopain Seminars, LLC

+ (voice)

+ (fax)

www.myopainseminars.com

dommerholt@...<mailto:dommerholt%40myopainseminars.com>

http://www.linkedin.com/in/jandommerholt

> IMPORTANT NOTICE

> This message is intended only for the use of the individual or entity to which

it is addressed and may contain information that is privileged, confidential and

exempt from disclosure under applicable law. If you have received this message

in error, you are hereby notified that we do not consent to any reading,

dissemination, distribution, or copying of this message. If you have received

this communication in error, please accept our apologies. notify the sender

immediately and destroy the transmitted information.

>

> Thank you.

>

> Bethesda Physiocare®

>