So Why Are We Out-of-Network?
As a surgeon that has tried to study everything there is to know about endometriosis, pelvic pain, and complex gynecologic surgery, I have become aware that insurance companies do not always recognize the value of what I can offer. For example, a typically trained ob/gyn can do a 1 hour or less surgery and cauterize a bit of endometriosis and will be rewarded with a relatively small amount of money by an insurance company. Over the years of my practice I have learned that this type surgery is more or less useless, and in fact the optimal treatment for endometriosis is a far more complex excision surgery than in some cases takes four or five hours or even longer, and always requires vastly more training and experience to perform. The problem is that an insurance company does not recognize that this more complex surgery is of greater value than the simpler surgery. This leaves the insurance contracted physician two choices - 1) perform an inferior surgery and probably not offer long term benefit to their patient or 2) perform surgery without adequate financial compensation for their time. And in #2 I mean this not metaphorically, but literally not enough compensation to create a viable business model.
Being out of network allows a surgeon to do what he or she believes is correct and set a fee that he or she thinks is reasonable for that service. It has been my experience that patients who are struggling with endometriosis value the expertise I can bring to their care and are willing to pay somewhat more to take advantage of that. This arrangement then allows me to offer what I believe is the best possible care while still operating a solvent and sustainable business model.
There are also situations where new therapies are being developed that are not yet adequately studied or are widespread enough to be recognized by insurance companies as medically necessary. For example, laparscopic neurolysis (neuropelveologic surgery) is a field that has great promise to help women with the most severe cases of endometriosis related pelvic pain. For the benefit of my patients and for my desire to understand every pathway to helping my patients, I study this field. That said, if I were an in-network physician there would be no way for me to charge my patients anything for this service, as it would be considered experimental or investigational and thus non-billable. In some cases, these techniques are not so much unproven as they are just unavailable. For example, there are only a handful of surgeons in the US that are trained to perform a laparoscopic pudendal neurolysis procedure (done for traumatic pudendal neuralgia, a very rare condition). This procedure will probably always be considered experimental, since there will never be enough surgeons performing it to create enough data to satisfy an insurance company. That said, the procedure is of tremendous value to the relatively few women who are affected with this condition and can benefit from the procedure. I am a physician is driven to understand and master these relatively rare techniques and offer them, even if there are few patients that need such procedures. Only by being out-of-network can one ultimately be compensated for this work.
Choosing to be out of network was a decision I made in 2018 to allow me to focus on providing the best possible care for my patients while receiving what I felt was adequate compensation for this work. It means that I can study with the best surgeons in the world, and travel to learn from any source that I can learn from, all for the benefit of my patients. To me that's an important thing. That said, being out of network is an imperfect solution to the difficult problem of inadequate reimbursement for complex surgical care. I am acutely aware that it limits access to my services for those that have poor insurance coverage or otherwise poor financial resources. I would be ideal if I could be adequately compensated to provide the type of care I provide within the contracted insurance system, and if that could be done I would do it.