What Really Happens With Medical Billing: What Patients Don’t See, What Insurance Companies Don’t Want You to Know, and Why Independent Doctors Are Disappearing

When you walk into a doctor’s office, you expect personalized care. What you probably don’t expect? That your visit may trigger hours of back-end battles-not with your health, but with your health insurance company.

As a practicing orthopedic surgeon running a hybrid in-network and out-of-network clinic, I want to pull back the curtain and show you what really happens behind the scenes of medical billing, how it impacts your care, and why so many independent physicians are being forced out of private practice.

Let’s break it down.

Step-by-Step: What Really Happens With Medical Billing

1. You schedule your visit.
   You give your insurance card. You assume that if it’s “covered,” there’s not much to think about.
2. The visit happens.
   I spend time diagnosing your issue, whether it’s knee arthritis, frozen shoulder, or something more complex. We may perform an injection, order imaging, or map out a long-term treatment plan.
3. The billing begins.
   Behind the scenes, my team submits a claim to your insurance company. That claim includes specific codes tied to your diagnosis and treatment.
4. The insurance company reviews your claim.
   Here’s where it gets murky. They may:
   • Approve it.
   • Deny it (often with vague reasoning).
   • Underpay it (less than the contracted rate).
   • Require additional documentation-dragging out payment by weeks or even months.

5. You get a confusing bill.
   Even if your insurance “covers” your visit, you may still get a bill due to deductibles, co-insurance, or unexpected denials.

It’s frustrating. For you-and for us.

What Insurance Companies Don’t Want You to Know

• Your doctor didn’t “overcharge.” Insurance companies often pay far less than the cost to provide the care-especially after administrative fees and overhead.
• Reimbursement rates haven’t kept up with inflation. While costs for medical supplies, staff, rent, and technology keep rising, insurance payments often remain stagnant or decrease.
• Insurance companies profit by denying care. Every delay, every denial, and every rejected claim helps boost their bottom line-not yours.

Why Independent Doctors Are Struggling to Survive

Running a private medical practice used to be a sustainable model. Not anymore.

Today, independent clinics face:

• Shrinking reimbursements
• Increasing administrative burdens
• Delays in payment that hurt cash flow
• Mounting pressure to see more patients in less time

All of this leaves doctors with a brutal choice:

Practice medicine the way they believe in-or sell to a hospital or corporate group.

What Happens When Corporate Medicine Takes Over

Hospitals and private equity groups are buying up clinics at a rapid pace. Why? Because healthcare is incredibly profitable-when it’s run like a business.

But here’s what gets lost:

• Time with your doctor. In a volume-driven model, you’re a chart to close, not a person to understand.
• Personalized care. Big systems rely on one-size-fits-all protocols and checklists.
• Access and trust. You may see a different provider each visit. Continuity vanishes.

When doctors lose autonomy, patients lose too.

What You Can Do as a Patient

1. Ask questions. Understand what’s in-network, what’s not, and what your actual out-of-pocket costs might be.
2. Support independent practices. When you choose care from a doctor-owned clinic, you’re supporting a model that puts patients first-not shareholders.
3. Advocate for transparency. Push back on opaque billing and fight for clearer, more ethical insurance practices.
4. Use your benefits wisely. HSAs, FSAs, and insurance reimbursements are tools you can leverage for higher-quality care.

Why We’re Fighting to Stay Independent

At Form & Function Orthopaedics, we’ve chosen a different path. We operate both in-network and out-of-network so we can continue to deliver personalized, high-quality care without being forced to compromise by bureaucracy.

We don’t answer to quotas. We answer to you.

Because your goals, your mobility, and your long-term vitality matter.

Final Thought:

Healthcare should be a partnership between doctor and patient-not a battleground with insurance companies in the middle. By understanding what really happens behind the scenes, you can make empowered decisions-and help preserve independent medicine for the future.

If you’re ready for orthopedic care that puts you first, reach out.

Visit f2ortho.com to schedule a consultation or learn more.