Matthew Vanderkooi says the single most important thing health care consumers should do to improve their outcomes is to tell providers which physicians they want to see − not the other way around.
By advocating on their own behalf and asking tougher questions, he believes patients are more likely to get treatment they need at a reasonable cost.
Vanderkooi independently owns New Life Physical Therapy in Portage, and also operates offices in Baraboo and Westfield.
He said he was forced to close a fourth office in DeForest a couple of months ago after some health insurers would not cover services for patients that his practice provided.
Vanderkooi said large health insurance networks have edged small businesses like his out of insurance panels, which draft plans for companies that work together to serve patients.
Because health insurance panels are based partly on relationships with other companies, private practitioners are left to fall by the wayside in some cases.
Insurance panels, also referred to as provider networks, are formed by health plans, provider groups or third parties, said Olivia Hwang, director of public affairs for the Wisconsin Office of the Commissioner of Insurance.
Hwang said panels might choose to contract with certain providers because they have larger established patient populations or already have contracts with providers with specific credentials or advanced degrees.
The Council of Affordable Quality Healthcare oversees a uniform application process, and any applicant can file an appeal if they are denied access to the insurance company they are trying to be paneled with.
Michael Decker, CEO of Divine Savior Healthcare in Portage, said his local health care network works hard to make contracts with all sorts of insurance companies and providers to ensure patients have access to the best care.
“It’s all about relationships, and we like to honor those relationships,” Decker said.
He said market competition helps keep prices down for patients.
Divine Savior Healthcare maintained relationships with at least 35 insurance providers in March 2017. At least 18 of those relationships involved Medicare Advantage contracts.
Among some of the big company names that Divine Savior Healthcare is tied to are Dean, Blue Cross/Blue Shield, Veterans Choice, Medicaid, Medicare, Quartz, Unity and Humana.
Decker said it’s important for patients to check with their health care and insurance providers to see if they are able to get treatment at their local hospital before making an appointment.
A Dec. 27 Wall Street Journal article states many large health care networks are pushing primary-care doctors to refrain from making referrals outside their network’s reach of companies. This keeps health care spending within the group.
Vanderkooi said this scenario played out at his office Jan. 16 when a patient said they could not see him for physical therapy because they weren’t given a choice on rehab providers and their doctor could not make any referrals outside of their internal network.
Vanderkooi said he chooses to write referrals to other providers outside of his offices because he wants patients to get the best care possible.
“We’re going to refer wherever the best value is for the patient,” Vanderkooi said.
Vanderkooi said he has had positive meetings with some larger networks’ administrators, and he hopes to keep the momentum going so patients can see him and be covered by their insurers.
“I am hopeful that going forward our market can be more focused on patients’ best interests, which is patient choice based on their needs, and buck national trends that are favoring big business at the expense of the patients,” Vanderkooi said.
How much patients have to pay and how much their insurance company is willing to cover depends partly on whether the two parties are in a network.
“Many insurance contracts that have networks also allow patients to see providers outside the network, although the patient will be responsible for paying higher cost sharing, Hwang said.
She said Medicare and Medicare supplements allow patients to see the doctor of their choice. Some insurance policies have no network requirements.
Decker said Divine Savior Healthcare agents walk patients through the processes and encourage them to ask questions if they’re ever unsure about anything.
“We try to help people know what they have and minimize surprises,” Decker said.
Helping educate patients and consumers is part of Divine Savior Healthcare’s mission, and the provider is involved in numerous community programs and fundraising efforts in businesses and schools, Decker said.
Decker said patients reserve the right to decide where they want to get treatment.
“It’s always the patient’s choice,” Decker said.