The Opt-Outs: Otolaryngologists extol the benefits of third-party independence

Dr. Asher, who sets aside office time each month for patients who can’t afford his full fare, added: “If I’m setting up an office that is totally out of network, I believe the services I have to offer are of value. I don’t want that to be an exclusive for people who have money.”

THE REFORM FACTOR

The wild card in how many otolaryngologists and other specialists consider moving to third-party-free practices is the uncertainty about how exactly health care reform will impact reimbursements. AAPS, which has sued the government to fight the law’s implementation, hopes more doctors move toward fee-for-service payment as they battle what Dr. Orient calls “ever more onerous and costly” requirements for record keeping and the potential for longer office waiting times as more people with insurance make appointments.

“In some ways, it will help my practice, because with the general lowering of reimbursement you will see physicians spending less and less time with patients and missing more and more things,” Dr. Gianoli said. “By comparison, the physician who charges a reasonable price and works for [the] patients, spending adequate time with [them], and practices good medicine will look like [a] superstar.”

Another potential hurdle in the future is how health coverage plans deal with reimbursement for out-of-network services. After Dr. Gianoli’s patients pay him at the time a service is rendered, they are free to seek some level of compensation from their insurance plans. Should the influx of newly-insured patients push carriers to lower or even eliminate out-of-network reimbursement eventually, patients might decide they can no longer afford to purchase that level of care, Dr. Gianoli added.

THE BOTTOM LINE

Dr. Robb said another benefit of not accepting insurance is that overhead is dramatically reduced since the provider doesn’t need to hire multiple staffers whose primary function is to “haggle and fight with agents and push paper.” There is, however, the issue of the up-front costs involved in starting a practice that relies on reimbursement from insurance companies. Dr. Robb estimated that when he started his practice he saved $50,000 to $150,000 of the start-up debt associated with practices accepting in-network payments, such as buying computers and software to comply with mandates regarding electronic medical records and billing.

Dr. Gianoli said a key to running the financial aspect of a third-party-free practice is to charge “reasonable fees.” His practice, run with partner James S. Soileau, MD, gradually eliminated its insurance contracts, starting in 2001. By the time the practice eliminated the last carrier, cash customers already comprised the majority of the business, but the bottom line required that the fees stay competitive. Boiled down, Dr. Gianoli said, out-of-network physicians can charge $2 for a service for which an in-network physician charges $5. This is because the physician outside of insurance collects all of the money he or she charges. The in-network provider may collect only $1 of the $5.