The challenge of creating a price list
The difference between what the practice charges and what the patient actually pays may make comparison-shopping for medical services particularly complicated. “Patients can try … but if the clinician accepts insurance, patients will not be getting an accurate picture,” Damle says.
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Adding further complexity to the issue, the Physicians Foundation reports in its 2016 Survey of America’s Physicians that only about 33% of practicing physicians are independent practice owners or partners.
“There’s a whole movement among physicians where they are moving away from private practices and being employed by corporations, medical centers and hospitals,” says Hollister.
Those whose practice is part of a larger network may receive their pricing structure from farther up in the organization, so decisions about what to charge are out of the practice’s hands. Whether this creates competitive pricing between medical centers and private practices may become apparent if they are all required to provide pricing schedules to patients.
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Add Medicare and Medicaid to this mix, and providing patients with a realistic picture of what they will spend for medical exams, tests and procedures becomes both simpler and more complex. The Centers for Medicare & Medicaid Services (CMS) has a maximum allowable charge (MAC) for each CPT code, and other health insurance companies use this as a starting point for their own price structure, says Hollister.
“They develop contracts with physician practices, and they develop percentages based on MAC, and that’s your fee structure,” he said. “This is not very patient-centric.”