| Jan. 5, 2010, Capitola, CA: Both the US House of | | | | medical networks charge medical practitioners a fee |
| Representatives and the US Senate have yet to | | | | for inclusion in networks. |
| address important details affecting patient care. | | | | The patient's right to choose their own medical |
| Oversight concerning the determination of medical | | | | practitioner is not federally guaranteed by law. |
| necessity as well as provider network inclusion issues | | | | Additionally, there is no guarantee an insurance |
| have greatly affected medical reimbursement and | | | | company will pay for medical services and patients |
| patient access to care. Many insurance companies | | | | often have no way to determine what will be paid |
| reimburse medical expenses based upon a | | | | until after a claim is submitted and a response is |
| determination of medical necessity by the carrier's | | | | generated the insurance company's claims |
| claims department. In the absence of external | | | | department. The federal government seeks to |
| oversight or regulation, the insurance carrier is free to | | | | mandate health insurance coverage for all US citizens |
| deny care based solely upon a private internal review. | | | | yet has not stipulated that insurance companies must |
| Another key issue not addressed is how provider | | | | reimburse patients for medical expenses nor is there |
| networks create financial barriers to care. Many | | | | language to address oversight of the determination |
| insurance carriers reimburse medical expenses at | | | | of medical necessity. |
| lower rates or refuse reimbursements for | | | | The determination of reimbursements is often based |
| out-of-network providers. Medical practitioners may | | | | on what is termed as 'usual and customary.' |
| also be excluded from insurance company networks | | | | Insurance companies have sole discretion over this |
| for a variety of reasons. Practitioners may be | | | | aspect of reimbursement for general health insurance |
| required to limit medical procedures for patients and | | | | policies and may choose to exclude many |
| the number of office visits as a precondition for | | | | procedures, office visits, and medical tests whether |
| inclusion in the insurance network. Medical practitioners | | | | or not teams of doctors agree that such medical |
| may also be required to accept lower rates of | | | | services are vital to the patient's survival, recovery, |
| reimbursement for services provided to patients as | | | | or comfort. |
| another precondition to network inclusion. Some | | | | |