HEALTH BENEFITS REPORT
Predatory providers will make us
pay in the long run
Most of us have medical plans with in-network
and out-of-network benefits. These plans were
designed primarily to use a network that, when
properly utilized, is affordable because of a con-
tracted rate that is usually about 90 percent of
Medicare-recommended rates. The out-of-net-
work benefit is there for when a deficiency exists
in the network.
Many providers have found a way to manipu-
late this system due to the generous compensa-
tion rate of the state (90th percentile of the FAIR
Health index). Providers seem gracious when they waive the
deductible and copay but, in fact, by going out of network and
incentivizing you to go with them, they are raising your premi-
ums. These costs are 3.5-4 times the in-network payments.
Not only is this practice disingenuous — it is presented to our
members as though they are receiving preferential treatment —
but it is against the regulations of the Division of Banking and
Insurance and increases your Chapter 78 contributions in the
process.
It is particularly disturbing that there are programs endorsed
by entities proclaiming their support of our members while ad-
versely affecting our premiums. At the very least, and when rea-
sonable, we owe it to our sisters and brothers in our plans to be
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NEW JERSEY COPS
■ DECEMBER 2018
responsible to each other.
Copays, deductibles and coinsurance are meant to direct
behaviors concerning decisions about healthcare value and
quality. The fact that providers attempt to circumvent this pro-
cess for their own financial gain, under the auspices of being
“friends of law enforcement,” does not help anyone. The state
gave a presentation on out-of-network reforms to both design
committees and we have had numerous conversations with the
Treasury Department on the current system, which is fodder for
abuse.
Having said this, out of network is there for a reason. Nothing
in this article is meant for you to make a decision that adversely
impacts your health or care in an acute situation or where there
may not be a qualified provider in network. Just spend a few
minutes and try to use in-network providers, which cost your
plan much less than out-of-network providers.
The Pathway to Progress is recommending that all public
employees be moved to a plan that is actuarially valued at 80
percent; this means that 20 percent of all medical costs would
fall on the consumer, more than doubling what we pay out of
pocket now.
If we don’t take measures to control these predatory provid-
ers, we will pay their bills in the long run.