Major changes in the rules governing surgery performed privately rather than through the public health system go into effect on Friday.
From that date on, for example, patients with supplemental coverage through their health maintenance organizations – programs such as Clalit Mushlam and Maccabi Magen Zahav – will no longer have to pay for the private surgery and then get reimbursement for it through the supplemental insurance programs. Instead patients will choose a surgeon from a list of physicians who have established a relationship with the HMO and the patient will then simply pay a deductible.
In addition, whether patients have insurance through a commercial insurance company or coverage through their HMO’s supplementary coverage, the surgeon’s fee will be paid by the insurer or HMO directly to the hospital where the surgery is performed, and the surgeon will be barred from demanding any additional payment from the patient.
The changes are being carried out as the first phase of health care reform legislation that was passed in the last Economic Arrangements Bill that accompanied the 2016 budget. The reform plan aims to reduce the outlays that the public is forced to pay for private medical care, which in practice means limiting payment that surgeons can charge for surgery that is performed privately rather than directly through the public health care system.
From now on, surgeons will have to negotiate their fees with the HMOs’ supplemental insurance programs or commercial insurance companies and the patients will be out of the picture.
In addition, surgeons who fail to negotiate an arrangement with the HMOs’ supplemental coverage programs or commercial insurers are likely to find themselves performing many fewer private surgeries because few patients are expected to be willing to pay a surgeon’s bill for a private operation, not when they have a wide range of options from surgeons who have made arrangements through the HMOs and insurers.
The second aim of the reform is to reduce bureaucracy and increase transparency when it comes to surgeons’ fees. The patient will make a single payment – of the deductible – to the hospital or other medical institution where the surgery is performed. In addition, the cost of any implants or equipment that the patient needs in connection with the surgery, which in the past the patient had to be paid for separately, will be included.
When it comes to commercial insurance policies, the new law will apply to policies issued from July 1, and to group policies the next time they renew.
Also, the HMOs and commercial insurance companies will not be able to provide coverage for reimbursement of the cost of consulting a specialist prior to surgery.
HMOs will have to publish on their websites the names of doctors with whom they have an arrangement.
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