Rationale for Endo Docs being Out of Network
Endometriosis is an invasive disease that invades deep into the tissues of the pelvis and beyond. Many studies have shown better results after excisional surgery than the commonly used ablation techniques, however the latter is what is taught in residencies and requires only average skills. Excision surgery, on the other hand, is very complex and requires advanced skills not taught in most residencies and fellowships. It can be quite time consuming, with typical stage IV cases taking upwards of 4-6 hours. Nationwide, there are less than 200 gynecologists who claim to specialize in endometriosis excision (out of 22,000 OB/GYNs). In reality, there are probably less than 30 who are truly skilled at excision and as of this writing in February 2022, only 14 have been video vetted by iCare Better, an organization formed specifically for helping patients identify true experts in endometriosis excision.
Let’s discuss the whole insurance system. Most doctors and healthcare systems have contracts with insurance companies that determine payment amounts and rules. Doctors agree to accept the fees predetermined by the insurance companies in order to be funneled patients by the insurers. The idea is that if they stay busy enough, they can accept less money for each given encounter. The problem with this whole idea is that healthcare providers have become “rats on a wheel”… constantly running faster and getting nowhere. It is why most checkup visits take 10 minutes or less, and in my opinion why patients are not diagnosed accurately or treated appropriately as nobody has time to stop and think, or even to really talk to their patients and take an accurate history. Moreover, the insurance companies have all the power as they make the rules and decide which procedures can be done and how much they will pay. Large corporations get more favorable rates than small one or 2 provider offices, and contracts mandate that the details of the contracts aren’t shared amongst practices. Doctors are forbidden to unionize and as such are incapable of mounting a fair fight against the insurers. This system is driving many surgeons towards doing the procedures that are most profitable and away from the less well reimbursed, rather than doing what’s right for the patients. Orthopods are doing more joint replacements and less preservation of natural joints because they are reimbursed better. Way better. GYNs are doing office hysteroscopy and endometrial ablations because they are paid almost as much as doing a hysterectomy. And hysterectomies are reimbursed about 2-3 times as much as excision of endometriosis.
There’s another problem with this system- as if it’s not enough that insurance companies are taking decision making power away from doctors and patients. It’s that the lack of financial incentives are a huge barrier to entry for gynecologists who agree philosophically that excision is better for patients. Because it is incredibly time consuming to learn excision and it pays so little, there is no reason to switch over other than doing the right thing. Fortunately there are still some people who follow their heart and want to do the best for their patients, but they are not in the majority.
Doctors are paid based on a system of codes called CPT (Current Procedural Terminology). Every procedure done “open” through a large incision (such as hysterectomy, appendectomy, bowel resections, etc.) has a CPT code that is used for billing. Some common procedures have separate specific CPT codes when done laparoscopically, but many do not and only have codes for being done open. There is one CPT code for laparoscopic surgery for endometriosis, and it is the same one regardless of whether excision or ablation is performed. Most of the procedures performed to excise advanced stage endometriosis (discoid bowel resections, ureterolysis, ovarian cystectomies for endometriomas) do not have specific laparoscopic CPT codes and we are forced to use what are called unlisted codes, which are generalized to a laparoscopic procedure on an organ system. Nearly all insurance companies can refuse to pay for these unlisted codes and therefore insurance reimbursement for excision of endometriosis is very poor.
Nearly all true expert endometriosis excision specialists are out of network for these very reasons. It is not our goal at Pacific Endo to be unreasonable with our rates, but to be reimbursed fairly for the amount of work, skill, and time that it takes to successfully and safely care for our patients with endometriosis. Many out of network (OON) surgeons are excellent, however there is not uniformity of skill or pricing. There are some OON docs who charge upwards of $20,000 for a surgery on early stage endo and they don’t even get out all the disease. I’ve operated on some of their patients afterwards. We intentionally try to keep our rates low because we don’t believe that good surgery for endo should only be for those who are well off.
We are not trying to profit from patients with a terrible disease but only to stay financially stable as the practice faces ever increasing expenses. I stayed in network for many years and saw my revenue steadily decline even as my volume and expenses went up. I felt like the rat on the wheel working 60 or more hours per week and making less than I ever had in my career. It is unfortunate that the system forces us to make this decision and it has not been taken lightly. If you want to change the system, please reach out to the administrators on Nancy’s Nook Facebook group and they can advise you on how to help the Endometriosis Advocates push for a more fair and equitable adjudication of claims and treatment of women with Endometriosis. If the past few years have taught us anything it is that groups of passionate people can change the world or at least the dialogue. The only way things will change is if women like you demand it. I wish you luck and will assist in any way I can.
Cindy Mosbrucker MD
Pacific Endometriosis and Pelvic Surgery