Home Forums Discussions General Discussion Venting!

Adam, I am with you totally.
In the old days, when I was with "The Group From Hell," we had a reimbursement schedule that was based on "production", otherwise known as gross billing. One of the group was an oncologist, who did chemo in the office. He saw a lot of Medicare, and pushed drugs like cis-platinum. So, he had these huge production numbers, but it was all "funny money". Oddly enough he felt this was perfectly equitable.

I have a similar ongoing argument with my accountant who insists on treating our accounts receivable as if ir were real money. I can not get her to understand it becomes real only when it is deposited in the bank.

"This means that the worst insurer (Medicare) reimburses in our geographic area at approx 50% of our asking price."

Adam,

Oh, the difference a state makes.....

We are in Maryland, which actally has the highest median household income in the country, as of 2009. Most of this income is the Washington DC/Baltimore suburbs. One would think insurance reimbursement would be fairly good in such a state.

Medicare is actually one of our highest payers. CareFirst, the local BC/BS plan, is comparable to Medicare. Most other private insurers are lower than Medicare.

I think, if I could say that Medicare was about 50% of a private insurer, I would think I died and went to heaven (at least financial heaven.)

The other disturbing trend is a marked increase in prior auths, for both meds and diagnostic studies (MRIs) since the first of the year. And while the prior auth, in the past, seemed to be "rationing by time", now we are getting rejections, sometimes after hours of staff time spent. And the insurers tell the patient "Your doctor can call and request a peer-to-peer review", so it becomes my fault.....

Sorry about the whine....

Gene

LauerDO,

My apologies for upsetting you. And, it appears you have found a solution that works quite well for your practice. I say more power to you.

JamesNT

a few things,

If you get a PM as an interim solution, remember that you will be using that software until every claim has been cleared. There is no transferring of claims from one PM to another. There may be a significant drain on your server and network.

Accounting software is the most difficult software to perfect, as you will lose patients over it if it is not rock solid. Don't expect the first version to be perfect.

Nationally, the average for unpaid claims is 17% as of a few years ago. This is the profit for the insurers. You are supposed to be to busy to fight for the hardest problem claims and be happy with a fraction.

As I grew, the best thing I ever did was hire a young person with the right skill set to be a good assistant to my in-house biller. I also have a program that guides them to the most important claims. You have to have adequate manpower and proper skills to dominate the insurers. They have to chase every claim on the telephone and fix anything necessary to get paid.

If you are getting paid 100% by any insurer, raise your charges!

Percent collections should be your revenue divided by your max allowable, which is different for every claim, over a time period.

While percent collections is nice to think about for comparing efficiency, it is unnecessary for your business. You need to think about your percent collections based on every insurer and for every CPT code to see if you are efficient or need to make changes.

Dan

Dan,


That depends on the situation. I have converted data from different PM's. In some cases it's pretty easy, in others it can be harder. The real question is can you get to the data. If the PM is online, you are truly at their mercy. If the PM is in-house, chances are usually fairly decent.


Not sure why you would say that. PM's use a database just like AC does and so won't cause any more drain than anything else.


By our experience, the commerical payors are angels compared to Medicare/Medicaid.


I don't think it's a matter of dominating the insurers. I think your point of having a good staff and doing follow-ups is key. Entering data correctly the first time is what counts. I see way to many:

* Patients with missing demographic information

* CPT's with missing modifiers

* Incorrectly mapped diag codes

Believe me, I can make that list long.

JamesNT

I will admit that "dominating" is a pejorative word, but this is on venting, so I splurged.

In rheumatology, we do the same thing repetitively, so we have learned all the rookie mistakes.

We have zero problems with Medicare, everything is electronic, they don't review claims, they don't lose claims and we are paid in 10 days with a report in 2 days on if something in the batch failed to process. Palmetto is our carrier, and they give us hospitality. This is very fortunate for us, cause you cannot get on the phone with Medicare.

Commercials slow pay, lose claims, review for 45 days and then ask another affiliated company to review for 45 days and then have 45 days to write a check. I have infusion patients with a balance of more than $10k needing their monthly infusion and we haven't been paid since November and they have been on the same treatment for years, with the same insurance.

I mean, I'm talking about California.

Dan,

We are in North Carolina. On our end, Palmetto is a creation of the Anti-Christ whose purpose is to destroy the world as we know it. The commercials are easy to get along with.

It appears we just have different experiences because of where we are from, I suppose.

JamesNT

I am with Dan. Medicare is now my favorite insurer, minus the MU stuff. It pays better than 80% of the commercials, is much cleaner to work with and never loses a claim.

Leslie,
If you are getting paid less than medicare rates you are getting screwed. I would speak to your provider reps and start dumping those who will not renegotiate your contracts. We shouldn't stand for this kind of treatment. You might be surprised to find that there are doctors right next to you, providing the same exact medical care and getting paid substantially more only because they demanded it. Just my opinion. I know nothing about Indiana.

My collection rate is 98-99% however, my medicare charges are one dollar above what they will pay therefore when Medicare pays us in full we know we need to increase our charges. I am in a retirement community and have 90% very complex medicare patients. When my Medicare charges where much higher than what Medicare would pay, i kept getting people trying to pay me the difference which i legally can not accept. It became much easier to charge what they will pay. It also made a better impression on the patients that I was not trying to charge a large fee.

That may not be such a bad thing.

Spyro,

Not to disparage, but you ARE causing our field/reputation as doctors to be lowered. The reason I set my fees is what I FEEL is my worth as a physician. When you set your fees at or above slight Medicare you are "giving in" to the government bureaucracy and saying this is all "I am" and my "services" are worth! Tred carefully!

Bert,

I know.

JamesNT

I know I just don't "get it," and have never been a part of the world most of you inhabit. But, why exactly does a physician agree let someone else tell them what he/she is worth? I charge X for service Y. It is a reasonable charge. I do not play documentation games trying to justify a higher charge. I do not do unnecessary tests. I follow guidelines. I expect to get paid for what I do. If someone has lousy insurance, that is their problem, not mine. I am willing to write-off anything in case of need, but not willing to let someone in Wichita tell me I am not worth what I charge. Their opinion is irrelevant.

Dr. Grauman,

Welcome to my world. I am appalled at the attitude I see in a lot of people when it comes to services I provide. So many people expect IT to be free. If I spend 4 hours making a custom report for someone, they freak out when I charge them for it. "It's just a report, how hard could this have been?" And, of course, that same person comes back a few days later asking me to add this field and calculate this sum on the exact same report.

$1500 server to run AC? Too expensive.

$1200 for a laptop? Why spend that when Best Buy has laptops for $399.95 all day.

Software licenses? Come on, James, don't you have a copy I can borrow: wink, wink?

I get that daily. And I get it from doctors, since that's what most of my clients are. The very same doctors that have a sign in the waiting room that says "Copay's are expect upon arrival."

The attitude you are experiencing is nothing new and it's everywhere. People want free - even people that would be your colleagues.

And it's getting worse. People dictate your price to you because they feel they have the right to health care.

People have no problem downloading music illegally because they feel they have the right to happiness and they equate that with being entertained. Got news for you, the US Constitution does not grant the right to happiness - and I expect about 4 people on this forum to screw that up and say it does. No, it doesn't. And what's so bad about it, people confuse the phrase from the Declaration of Independance.

I wish I had a solution for all this, I really do. I guess you and I get to just deal with it.

JamesNT

Come on, James, don't you have a copy of WS2008R2 I can borrow: wink, wink?

Jack and David,
I would love to somehow reconnect the prices that I charge for my services with what I think they are really worth. Unfortunately, these are completely decoupled in our current system. I recognize that non-participation with all insurers is the way to rectify that. Unfortunately, that is simply not an economic option for me at this time. It is also not feasible for most of my patients to pay for my services in any other way.
In the interim, I do not believe that it "lowers the reputation of our field" to recognize the reality of the situation and set a price which nearly matches the predetermined reimbursement. That is not what I do, but I have no illusions that I somehow change the insurer's perception by consistently setting my prices higher than what they pay.

And James, I think you may have accidentally posted to the wrong forum. This is the one where doctors bitch about insurance companies not paying us what we deserve; you meant to post on the forum where IT people bitch about doctors not paying what you deserve. I am afraid you may not get quite as much sympathy here....

JBS,

Excellent point.

JamesNT

Brock,

Respect your elders, my son. I MAY BE YOUR FATHER!! <insert breathing pattern>

JamesNT

My son the IT guy for MD offices was doing just that last night. I had a sympathetic ear, because I have to.

Reading these posts is like seeing the news. Every evening I go home and breathe a small silent prayer of thanks that I do not live in Somalia. And another one that I do not have to deal with many of the issues the rest of you do. It angers me on your behalf.

But, Jon, I will say that one of the reasons I opted out was that it gives me much more freedom to writeoff what a patient cannot pay. I feel much better about myself if I charge $500 and writeoff $400 than if I just charge $100 in the first place and pretend that is what I am worth.

David,
So if I have 100 indigent patients with Medical Assistance who need colonoscopies, then it will make me feel better to charge each one $500 and write-off $375, rather than just charging $125?
I suppose that I no longer base my sense of worth (and the value of my work) on either my fee schedule or what I am paid.
A school teacher could submit a bill at the end of each school year: "For services rendered, my charge is $100,000". Does that somehow change things if the salary is still $40,000?

Well, yes, it reminds me that what I am doing is valuable, and that I choose to be charitable, rather than leaving me feeling used. I like being charitable; I hate feeling "taken." And, much more of the time I actually collect my "usual and customary" fee from non-indigent patients. If I accept the view that my fee is actually the lower value, then that's all can hope to collect ever.

and the UCR will never go up.

But, charging exactly what you will be paid will reduce clicks for your billers, and that is a true religion.

Thanks for the all replies. Useful.

HEDIS manure,

I got letter from insurance company that only 28% of my diabetics got good care. Didn't say everyone got A1C, blood pressure control, Lipid, Diabetic foot care, Microalbumin/creat ratio done. I ordered diabetic eye exam on all but only 28% completed it so guess who gets the blame. We are noticing a pattern. We are only getting 1-2 requests from each insurance company listing one or two of our most non-compliant patients and they no longer accept our reminders sent for needed care or care that was ordered and not done. Also reminders sent don't count or letters sent to them stating we will no longer be responsible for adverse outcomes but to their lack of failure to get care (works on most patients as they don't want to take resposibility for their own care). We are now held responsible and the patient has NO responsibility for this. We will soon have to show up at their house or work and forcibly bring them in for care. Doesn't make sense to me.

Early on, a friend on the Family Medicine faculty at U/Washington noted the downside of any Pay for Performance plan.. that physicians would start dumping non-compliant patients. Somehow, personal responsibility on the part of the patient has to be built back into the equation.

I cannot imagine any system that will EVER hold patients' feet to that particular fire. The complete teardown of the current system and a rebuild from scratch would probably fail too, because politicians, special interest groups, attorneys, etc. will want to control the process. Down with dumb HEDIS.

Unfortunately the only recourse is to tell patients if they will not get testing and referrals as ordered that you will be unable to care for them - sounds good but my numbers are not great either as I cannot bring myself to fire patients not to goal - I have one patient with a 8.5 a1c who makes me look bad, but since it is not the 15-16 it was I feel like I am making a difference.

I do not even read those stupid things...they go right in the trash.

same here Leslie, I don't read those reports. I didn't ask for them and don't want to see them.

The problem that is quickly coming onto the horizon is that your reimbursements (all of them) will be reduced if you don't have 95% of your diabletics with "good care." Your only recourse becomes to drop the patients or drop the insurer. This is what I have always not liked about the "pay for performance" trend in medicine. And even before this trend, the malpractice situation whereby if you don't document that you REPEATEDLY reminded the patient of the consequences of not going to that referral or taking that test, it becomes your fault. Because as soon as they have a "bad outcome" they are going to be mad and of course it is NEVER their fault for refusing to follow advice. At least in their mind.

I have found something useful in the unsolicited reports that often come from the mail order pharmacies, saying that the patients are noncompliant because their meds are not being refilled enough. I give them to the patients. It lets patients know that big brother is watching, and they will often get back on track, fearful that there will be repercussions on their insurance coverage. And when the PBMs are wrong, patients have the telephone number to call up and tear up the first miserable Medco or Caremark phone rep they reach.

This thread on "venting" has taken various twists and turns; maybe it should just continue forever as an open invitation to... well, vent.

Pay for performance is here to stay, and I don't think we can stop it. Actually, I don't think we should try. What is essential though is to fight inappropriate implementation. The example Steve brings up is a perfect one. I would suggest a well-thought out (if ultimately, "templated") letter along these lines:
"I am in full agreement with your goal of providing superior diabetic care to your premium members, and I also agree with your stated plans to compensate me at a higher rate for providing such care (though I have not yet received such payments). Please note from the attached print out that 95% of my diabetic patients had an A1C, blood pressure control, lipid testing, diabetic foot care, and microalbumin/creat ratio done. Also note that I ordered diabetic eye exam on all. Please note that I have implemented an EMR at considerable time and expense which allows me to provide this precise documentation of my superior care to you.
Unfortunately, only 28% of the patients chose to get the eye exam which I recommended. How do you propose to improve this rate? Can you do something to make access to eye care easier and perhaps cheaper for my patients so that they will be more likely to follow my recommendations?"

Jon,

I agree wholeheartedly that Pay for Performance is here to stay, but I can't disagree more with you that we should do everything in our power to stop it--I have been crafting a letter to our two senators, one is Senator Baucus who has been very involved with the Affordable Care Act. But the point you make about shifting the responsibility onto the physician is the clever way to decrease cost and penalize us for the noncompliant patient. In this Brave New World, my office is now termed the reporting station, and the patient doctor relationship is now null and void. We are now instruments of the state somehow magically able to control our patients so all of the quality metrics are fulfilled, and if not the physician is financially penalized, and thus health care costs are reduced. By implementing an EMR to improve efficiencies in the office (oops, I meant to say reporting station) we are handing a butcher knife to the state to trim all the unnecessary fat from the present health care inefficiencies, and thus health care costs are reduced and care is magically improved.
If 28% of your patients do not get their eye exam your performance is subpar and you will not get your performance incentive payment, and you multiply that factor by a few thousand and health care costs will be significantly reduced at the physicians expense, and will occur more likely to the physician who is willing to be innovative and adopt an EMR and acheive all the stages of meaningful use.

Now, maybe I am still quite upset about my 1% penalty for not eprescribing by June 30th of last year, but it woke me up to reality--this is no longer theory, old jimmie boy and his family may not get to vacation this year.
Hopefully I can get my check for stage 1--I am still in the process of doing this and way behind the curve as you guys have been at this a lot longer than me.
Alright I have exposed my flank--let me have it, I am extremely shy by nature and verbal dexterity, as you can see, is not my strong suit, but I am trying to see some advantages to the future of medicine with the Affordable Care Act, but just having difficulty. jimmie

Docs4 patient care. Please join ASAP!

Jimmie, believe me, I am sympathetic to your plight. My initial statement was more a matter of pessimistic acceptance; I applaud your activism.
The gist of my comment was that we should fight back against a seemingly immovable force by battling the specific injustices of the program. If the specific rule is absurd (are we to prepare their food, inject their insulin, and drive them to the eye appointment?) then we should fight the insurance companies, and work together on strategies to do so!

Only a small percentage of eligible practitioners have gotten their incentive; you are not far behind. There is a whole cadre of "consultants" here ready to help you get it. Feel free to share your specific issues.

Jimmie, we have never met, but by your posts, you seem to be pretty insightful, savvy, and good with words. I have no idea about your verbal dexterity, but so long as you are here, who cares? We only write and read!

Jimmie, you are certainly as good with words as anyone else here. Believe me when I say, as one who often represents the "lunatic fringe" view, that you have a very safe and supportive audience on this board. The fact that you are here is all the qualification you need to express yourself however suits you. Go for it!!

thanks for sharing Jimmie, and I admire your activism. I have written my senators and house rep only on the matter of the medicare cuts that recurs annually. Good job!

I've posted previously here that a nationwide strike by physicians, if everyone and I mean everyone participated, would bring ALL players to the table after approximately one hour of the strike. And by the end of the 4th or 5th hour of patients in the ICU dying and patients on the O.R. tables having bled to death, I think we would have whatever terms we wanted. An extremist view? Absolutely. Likely to happen? Not at all.

The biggest problem is that physicians by nature are too independent and with such varied viewpoints, this will never happen. But oh boy if it did....we would have whatever we wanted.

Can you imagine if Pres Obama's mother were in the hospital and physician's went on strike? He would come to the table ready to talk Tort Reform for the first time ever, the Medicare reimbursement debacle would be fixed, and the MU scam would come to a grinding halt along with all the P4P scams. We would have true fee for service and improved reimbursements. I think Congress would agree to have physicians paid whatever we wanted.

Again I ask: will this ever happen? Probably never. I honestly don't think our physician leadership (AMA/AOA) could ever agree on what terms we should get if we all went on strike. I may be wrong here, but I believe physicians are federally forbidden from unionizing. But what are they going to do? Throw us ALL in jail? Go ahead...that would get us the strike that would fix everything. However if there was a national strike, I think it would rock the foundations of medicine in this country to its core. And maybe just maybe we would stop being the afterthought in all of the national discussions, and the law makers would come to us FIRST rather than AFTER the law has been determined.

By the way, Happy Easter all. For all of us Christians (at the high risk of offending all of our non-Christian friends, sorry) and for the benefit of ALL human-beings Jesus allowed himself to be tortured and killed to pay for our sins in-advance of us committing them. then He rose from the dead to prove that not only was He the son-of-man but also through Him we shall have eternal life. For this I am most grateful. Enjoy the day with your families.