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Just imagine if other common industries did things the way the healthcare industry does things.

I suspect that most of us are familiar with the terms “in-network” and “out-of-network” when it comes to our healthcare insurance, but there are a lot of beneficiaries who may not be. Allow me to provide an analogy, a distinction, in an industry that we are all familiar with, to potentially provide clarity: the restaurant industry. This is an event that did not occur, and hopefully never will.

But let’s suppose for a moment that for my wedding anniversary, I wanted to take my wife out to eat at a very special, elegant restaurant. I called a few days before the date; I wanted just to make sure that I could get a reservation. When I called, I was asked several questions:

  • Have you ever dined with us before, so we can pull up your record? I said “no.”
  • Do you have a dining membership number? I said “no,” and asked what that is. They explained it’s a way for us to see if you are in our network of restaurants, and how payment will be rendered for services ahead of time. All restaurants are apparently using this process now.
  • If not, what are the last four numbers of your Social Security Number? We can look it up that way.

Once I got all of that resolved (or so I thought), I gave them the date and time for the requested reservation. I was informed that they would call me the night before and tell me what time my reservation would be.

When we arrived at that predetermined time, we were seated, but before being given menus, we were approached by a person who asked us how we plan to pay for the meal and requested a credit card number. I innocently asked why that was needed and was informed that, since I was out of network, they needed to guarantee payment ahead of time.

Finally, we were given menus, and I noticed there were no prices. When I queried about this, I was told that prices are based on their network charges – but since we were out of network, our prices needed to be determined at the end of the meal, and they vary depending on the program.

When the meal was over, we received multiple checks and were responsible for all balances, including services provided by:

  • The chef, who was a steak specialist, but could cook other items at extra cost;
  • The waiter;
  • The salad specialist;
  • The dessert specialist;
  • The dishwasher; and
  • Three others.

Needless to say, our night was less than special, not enjoyable, and unexpectedly, more expensive.

Now let’s fast forward to the real time and place: today’s healthcare environment. My imaginary restaurant scenario is analogous to what we are dealing within the healthcare world every day. The “No Surprises Act” is designed to prevent or minimize such consequences in our medical billing. Thankfully, there is not a need for similar legislation for other industries – yet!

Finally, I would request of readers to please leave comments so we can learn how to better provide you with entertainable yet educational commentaries regarding our healthcare system.

Programming Note: Listen to Dr. John Zelem every Tuesday for his live segment, “Journaling John MD,” every Tuesday on Talk Ten Tuesdays 10 Eastern.

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John Zelem, MD, FACS

John Zelem, MD, is principal owner and chief executive officer of Streamline Solutions Consulting, Inc. providing technology-enabled, expert physician advisor services. A board-certified general surgeon with more than 26 years of clinical experience, Dr. Zelem managed quality assessment and improvement as a former executive medical director in the past. He developed expertise in compliance, contracts and regulations, utilization review, case management, client relations, physician advisor programs, and physician education. Dr. Zelem is a member of the RACmonitor editorial board.

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