Guys before you all end up owing, yes f'ing owing these bastards lots of money you are only half right. Yes it is your business and I guess you can do whatever the heck you darn well please in terms of billing and policy but here is where it gets sticky. And worse yet if you end up on the wrong side of this with the carriers or worse the gov't Medicare ya, but state Medicaid (NYS loves this Wayne, please be careful) you could be in serious hot water. Please I don't want to hear of any of you getting raked over by some state AG or something. You have been officially warned as of this next statement!!
Let's use that same 99213 with the $75 charge in a typical PAR practice. Now lets assume like here in CNY that Medicare pays approx (public infor no discloser and talking issues here) approx $57 for this charge so now you charge $75, get $57 and write off $18. So far so good, right. Meanwhile let's just say for arguments sake your local BC/BS pays about $65 for that same code, so you Charge $75, get $65 (no copay for now) and write off $10. Everybody with me so far.
So in come little Sally Single Mom with a McJob and she has McBenefits (none). So seeing that the gov't only pays you really 80% of $57 that you then need to do a double claim on just to get your full $57, and none of your local carriers meet your charges anyway, let's say for argument sake again you charge her $50 cash on the barrel, Paul and Nancy's favorite, PIFATOS (pay in full at time of service). Well since these SOB's are a real CARTEL and can and do talk among themselves and share all sorts of data, they are going to try and track your claims. So they want to see how you charge EVRERYODY!!! Well it turns out that you really aren't charging "everybody" that same $75 for these level 3 est patient visits, you are really only charging some and not all people, especially insurance carriers and the gov't!!! Red flags and lawyers everywhere!!! They can and will argue that you frequently only charge $50 for this 99213 code especially to private pays and only charge the carriers your full $75 charges. They can and will force you under threat of insurance fraud charges to reduce your charges to some form of any average between the two of $75 that you have been charging only the carriers and the $50 you have been charging your PIFATOS patients for cash on the barrel.
If you are lucky you will only have to borrow tons of money from friends and family (the bank certainly won't here) to give these bastards their "give back" for over charging, as well as pay your team of lawyers and quite possibly a nice tidy fine too. And good forbid CMS and the Gov't gets wind of this, now you are really in a world of pain, NO CCHIT! Now most of us will probably never under charge past Medicaid and only those who accept and charge straight Medicaid really have to worry about that, but if you should ever be on the wrong side of this same issue with your state medicaid, just slice your wrists and get it over with, because you are truely screwed then. There is no prosecution against a doc that is more extreme and you are going up the river then a state medicaid fraud charge, trust me. You never even want to be only one step on the correct side of this on. Never give them half an inch to get near you. Always avoid anything that can remotely seem like you are messing with these guys, because if they ever get a hold of you, you are toast!
Their logic is based on your own charges, you don't really charge "X" for these services, you only really charge "Y" for them and so therefore you owe us lots of money and possibly a penalty too. If you are really lucky they may just let you work for free until you have done enough free work for them to equal at their rates not your own, what you owe them in give backs. Heck they do this to folks simply based on poor charting and documentation, you don't think they are just waiting like hungry wolves to catch you doing this stuff. Sure right....
Lastly, each and every time each and everyone of us submits a charge it should be going into the community rate figures that these SOB's collude on all the time. We as a group don't want to be officially reducing our rates ever! This is the main reason Congress in it infinite wisdom gave these SOB's their anti-trust waiver in the first place. To set the community rates and a lot of that is based on what we charge verses what they pay out. This is where Usual and customary is supposed to come from.... So everytime one of us under charges we are really only hurting ourselves.
I'll end on this question..... When was the last time one of you actually bumped up your fee schedule??? Goodness knows that except for one or two charges we have not had good reason to bump ours in over three years now. We set one when we opened, and things went modestly up and so we were slightly undercharging on a few things, I review our schedules from various payors, and made a few adjustments that second year and since then we haven't had any payment increases in the last three years to justify adjusting it again.
We (us and you too) are all probably charging too little as it is, especially in light of all the crap these sob's have us do for them and their "system" each and every day. I refuse to continue to slide backwards from here. My G&E bill hasn't slid backwards, neither has my rent, nor has Nancy's Malpractice (actually here in NYS our has just about doubled since we opened only just about five years ago this coming month) for that matter. Instead of giving in to this backwards slide, we need to insist that the money be redistributed where it actually belongs, not going to CEO's of drug and insurance companies, but to the professionals on the front lines providing healthcare in this must messed up situation here.
Although I may not be cranking Nancy's fee schedule up, I certainly refuse to reduce it one cent. It is time for people to understand that quality healthcare is going to cost some money. And the money for the most part is already there, we are just allowing the non-provider side to steal and keep all of the cream scraped off the top and they are not sharing it with neither the patients in terms of better care, nor you the providers in terms of proper fees. Especially office visit, rubber meets the road type fees. E&M "Management type fees... Screw that. me personally I'm going to try and at least to not slide backwards, I'm going to try and keep U&C at least where it is. My wife worked too hard to get where she is today to be mistreated and underpaid, and disrespected so. Our fee schedule holds, it is not that bad in the first place.
Most lawyers are getting $250 or more an hour these days. They studied at least 4-5 years less than any of you and don't get woken from a dead sleep 3-4 nights a week, they are not on call 24/7 and they are not being hunted my themselves and the gov't at every turn. Don't you feel you are worth at least as much as the average lawyer??? I certainly do....
