If insurance is just an entity taking over payment over for a policy holder, can’t all practices take all insurance? Why should it matter which entity is footing the bill? They’d be happy to charge me full price, regardless, and I’m not an entity with money. Trying to find a dentist that takes Medicaid is hellish.
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The provider may not want to, since some insurances may try to pay such low rates to providers that the provider may see at as not even with bothering with. Some state Medicaid programs in particular are notorious for offering rates far lower than providers ask for
because insurance don’t get charged full-price. private insurances will have their own negotiated price with hospitals, and will only rarely get charged full-price (say if you’re admitted into a hospital out of their network due to an emergency). even then they’ll probably still be able to haggle and find loopholes on prices, or set a maximum limit to which they’ll reimburse you.
medicaid and other public health insurances are the same. in fact, they set their own payment rates, and leave up to the healthcare providers whether or not they’re willing to accept. these payment rates often barely, if at all, make up the cost of the service provided, which is why many places will not accept medicaid. other places may accept medicaid for the supplemental benefits they receive if they do.
ps. this is also part of the reason why healthcare costs are so broken in the united states. insurance want to pay less than out-of-pocket patients, meaning hospitals will just raise their prices to make up the difference.
Participating in insurance means that they have negotiated rates with each insurance company. Some pay better than others. Each has different requirements in order to receive payment. Its a lot of work on the provider’s part to send in the bills, review the payments to make sure everything is correct, write off any negotiated rate, and then figure out how to collect any balance from the patient
Can’t all practices take all insurance?
Sure.
But insurance doesn’t want that, because insurance is a business that wants to turn a profit. Accordingly insurance contracts with certain practices to receive work at a lower-than-customary rate. In exchange the insurance company tells their customers “We only cover care X at practices Y – our ‘in network providers'”
Because insurance is generally free to set such terms practice Z can’t accept that policy as payment, because the insurer will say “You’re not in our network, the patient has to pay you.”
It isn’t that the provider “won’t take” your insurance – rather it’s that the contract *you, the insured patient, signed* says your insurance doesn’t have to pay them.
The issue is that insurance will cap its payment at some level below the doctor’s full price. Many out-of-network doctors will bill your insurance and take any payment they receive from them and apply it to your bill, but will then bill you for the rest. But your insurance may not pay for out-of-network doctors. And even if they do, if your doctor is in-network with the insurance, they will accept the insurance price as payment in full, which is a powerful incentive to go in network.
Insurer A will pay $100, Insurer B $200, and Insurer C $220 all for the same service. If a doctor can fill their schedule with patients from B and C, why would they take A?
Medicaid is a different problem altogether. The problem with medicaid is that they pay even less than most private insurance – so low that many practitioners just literally can’t afford to stay in business at those rates. And the medicaid rates aren’t negotiable.
Most insurance companies negotiate a bulk rate discount with the provider.
Medicare and Medicaid, in particular, demand a very steep discount that not all providers are willing to accept.
In addition, every insurance provider has their own paperwork requirements, their own list of what services they will and will not cover; it’s not usually worth it for a practice to learn all the details of every single plan when they can fill up their appointments with just a few.
(Bigger practices usually have someone on staff whose sole function is handling insurance paperwork.)
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