Negotiating Your Reimbursement Rates during this Phase of Payer Consolidation & Health Insurer Monopoly Power

Physicians’ choice of health plans and contracts seem to be getting fewer and fewer with each passing moment as U.S. health insurance sector, particularly the private sector, witnesses unprecedented payer consolidation, acquisitions, and mergers amongst private health insurance carriers. Besides contradicting the hope that such consolidation, acquisitions, and mergers would bring down the cost premiums for patients, it has virtually helped a few players to wield monopoly over the entire commercial health insurance landscape. The situation has grown so unchecked 70 percent of 385 metropolitan areas in the U.S. do not have competitive conditions, and as much as 40 percent of these areas have a single health insurer controlling the majority share of the commercial health insurance market. As a result, physicians have virtually lost the bargaining leverage that they would have enforced had there been a perfect competitive market for commercial plans.

Physicians only source of revenue is from reimbursements from services they offer to patients, who may be supported commercial health insurance plans or public programs, such as Medicaid and Medicare. With most of the commercial health insurance market moving toward monopoly, physicians, mostly those practicing in small groups, are finding it difficult to negotiate adequate reimbursements. As a result, those insurers with monopoly powers are dictating the payment rates, which are often below the acceptable scale. Such unilateral administration of payments could leave physicians struggling to meet their financial obligations, obligations, including payroll, and to invest in and sustain desirable quality of medical care to their patients.

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Even the thought of accepting public insurance plans may not prove to be all that profitable – most of the patients may not have the resources to pay for out-of-pocket expenses well above the rates borne public programs, such as Medicare and Medicaid, whose rates are deemed insufficient to cover for a decent quality of medical cost. Thus, small physicians are often left with no choice but to accept rates dictated by dominant commercial insurers.

While the physicians associations have voiced strong protest against health insurer consolidations, in particular, mergers between two health insurers which threaten to create a single insurer with absolute power, it may take a while to disintegrate the trend towards a competitive market that can bring back bargaining power to physicians and patients alike. Till such time, physicians may well have to be content with rates as fixed their commercial payer. Alternatively, they can entrust their Medical Billing processes to an external entity that can use its competence and experience to arrive at as profitable a rate as possible. 

Medicalbillersandcoders.com – which has been a preferred platform for comprehensive medical billing resources – can help physicians impacted with the trend of commercial insurance consolidation. Our nation-wide affiliation with chosen pool of medical billing experts helps us to deploy resources that enhance medical billing efficiency, reduce the possibility of delay, denials, and improve practice revenues. Their expertise and experience could easily be extended for negotiating as best a reimbursement rate as possible even at this juncture of commercial payer monopoly.