Home Forums Discussions General Discussion Medicaid Increases

I didn't think anything would be more newsworthy than canceling the ACUC. But, Medicaid has made HUGE increases in its reimbursements for those in underserved areas. Unbelievably big!

I haven't been this happy to be a doctor and go to work than my first day out of residency. It's even retroactive to October 1. I am seriously thinking of closing my practice to private insurance.

Bert.....

Well, that is just in Maine for now. Supposedly Medicaid rate are to be brought to Medicare rates nationally in 2013. In many cases this does amount to huge increases. Illinois, as usual, has been silent about it, but the state is practically bankrupt (2 of our last 4 governors are in jail) so even with the 60/40 federal state split, more money is a bigger budget. If it became retroactive I would shout for joy.

It's that socialist president and his d**n ACA. It isn't just in under-served areas; it is for all primary care providers, though as with all Medicaid fees, the states have a lot of control about how it is administered.

No, it's true it isn't just underserved areas (but 40% of children are on Medicaid) and yes, states do have a lot of control. These increases are due to the ACA so I don't have a problem with them. When you only generally pay 60% of Medicare rates as Medicaid does, in general, you get underservice. You get what you pay for!

Then again, I have an issue with basic health care not being covered for all citizens, like the rest of the first world. It IS a radically socialist idea

Here it is only underserved areas. At least that is what it said.

@Todd What is Bert....

The increases I am referring to are controlled by the state.

Here is a pretty good description of the program that seems relatively unbiased.
The table at the bottom is useful for seeing how your state's Medicaid program compares to others with regard to Medicaid reimbursement.

Don't see the table. I am very naive about this so please inform me if I am doing something wrong talking about this, and I will delete. Our letter actually states, "...those accepting Medicaid and are located in an area with a Governor's designated medically underserved population."

Many of our reimbursements are higher than BC/BS and other private insurers. Plus no copay. Others are up by more than 50%. All are Medicare or above.

I am delighted for you. I am also left speechless at how terrible it must be to try to make a living if you are celebrating being paid at Medicare rates.

Forgive me if I just don't get it, but when I look at the Medical Management Institute tables of physician income, our income is pretty much right in there with that of most primary care physicians. But, if we had any significant Medicare practice, we long ago calculated we would have been bankrupt. How on earth is this possible? We see about 12 patients a day, and can't really do more because of their complexity. If we saw Medicare and charged each a 99215, we still wouldn't make it.

Yeah, but when I first opened my practice and up until now, when I see 25 patients, 18 of those are Mainecare. It's an abuse of the system, but they GENERALLY don't work and given they don't have to pay anything, they bring them in. It's also because of the system since if they don't bring them in, DHHS will swoop in and take them. And, if they bring them in too much, and God forbid get B12 shots with a B12 level of 92 and a RBC diameter of 200, they call out office.

So, I must admit there are times at 5:15 when a conj called, I would ask the insurance. Now, if they are Mainecare, they will come in. Now that they pay more for WCC than Aetna and Cigna and BC/BS and they HAVE to get shots (good reimbursement), and they HAVE to come to ALL well child visits, something 35% of private insurance patients don't (or more), I stand to do better with Mainecare. Also, as stated, private pay are MUCH less likely to do shots than Mainecare. Our Mainecare rate of immunizations is about 92%. Our private is about 73%. You do the math. Four shots times the admin fee. Damn that Pentacel. Yeah for splitting up MMR-V.

And, I don't feel bad for playing the system due to being screwed for so long. Our rates for f/2 is over 80% for Mainecare and about 50% of private. Add to that that private won't even make the f/u appt.

We also are number one in the state for Pay for performance, which is not something you have to even think about; this includes the fact that I am the only pediatrician who doesn't do leads or HBs and doesn't do PAP smears. We are also number one in the state for prior authorizations to Boston and for medications, which pays nothing but makes us excited.

Being number one for Pay for performance pays me more than half of my salary, i.e. Salary + 60% of salary.

Sorry, just had to throw that in there and reveal how one can make decent money with Mainecare. It did frustrate me in the past (and now still) when I was getting 50% of private, but that is changing.

The most frustrating thing is when I was getting X amount of dollars for an ear infection while the FQHC across the street was getting three times the amount with no liability insurance, no taxes and a $650,000 stipend each year for infrastructure. And, very nice that the government is paying for Logician/Centricity for each workstation, which talking about consults, produces absolutely the worse note ever. Even their doctors come to me and ask about AC, but they can't get it.

@Leslie Talk about your medication list, they list it three times and not just "Concerta," but Concerta 36 mg Extended Release Capsules blah, blah, blah....

And, if you charged 99215s, you would be audited.

Last time I checked I had only 4 straight medicaid patients in my practice, as a result of about a decade ago the large multi-specialty clinic in town sucked up all the medicaid patients.
However, the table Jon sent is insightful, and did not know there was so much variability in medicaid reimbursement state to state, but maybe I should start seeing more, and Alaska looked to be the best reimbursement of all.
To play the devil's advocate on medicare--it is a steady every 2 week paycheck (generally) the annual wellness exam tied with a 25 modifier and a 99213 generally is as well compensated as a private straight annual exam--and the medicare patient does not have any out of pocket expense for an annual exam. (usually the younger annual exam patient is simpler and more difficult to justify using the 25 modifier, and if you do he will get upset with the bill especially if his insurer does not cover the annual.)
So call me crazy, but I would prefer medicare patients now that medicare is finally reimbursing us for doing annual exams, which we just took in the shorts for years until 2 years ago when the annual exams started getting reimbursed.
I would not do a 99215 unless you want to get red flagged for an audit by the medicare police.

Two thoughts
1. No one is being denied care as I don?t see bodies stacked up outside locked hospital doors.

2. Now the unreimbursed hospital costs are ?distributed or passed on? by a Hospital administrator to private and government payers one way or another. Sneaky but efficient. Under Obamacare YOU will pay additional taxes which are floated out into a sea of bureaucrats and politicians. When this Federal tide goes out hospitals and practitioners get what remains (think pond scum). You will agree nothing is free.

(As an aside...Every couple months newspapers carry an article about practitioners or medical supply houses which have ripped off medicare for 10s of millions of dollars. Some Miami, Fla outfit got em for $20 million in August, Utah penis pump $10 million scheme in July etc. When was the last time you saw ?United Health Care Defrauded of 20 million dollars??


And their wealthiest citizens seek care in the United States. Frequently at the Cleveland Clinic where I can now, at least, freely refer Medicaid or Medicare patients. Tour Italy, Brazil, Argentina, Sweden discover the two-tiered system public and private. Not in Canada of course since we, at least for now, are the private care for the Canadian swells.

Wendell...to quote Mr. Bean, be afraid, be very afraid my friend :-)

Bob, I am not sure what your point is. First, they are being denied care. MaineCare patients HAVE to go to the FQHC and get inferior care as I cannot take care of all of them over and above the hospital center. But, there are many VERY GOOD doctors who do not see MaineCare.

I guess it is different in every state, but here it takes an act of God to get a patient to the Mass Gen or Boston Children's.

For me (and I exaggerate), I would rather pay $25.00 in tax for each patient and be reimbursed $75.00, than to get $50.00. I know it's the same, but psychologically....

I don't quite understand how the Medicaid/Medicare fraud comes into play in relation to the Medicaid increases.

I am afraid you picked a REALLY bad example to make your case.
$20 million is pocket change to this guy.
Don't worry about him, though: he still made off with over a billion dollars from UHC.

I assume the very good doctors aren?t just sitting around but have a full schedule. You will need a sudden influx of good doctors to the state though I see your point re some referrals to select specialists perhaps. I?ve never considered refusing Medicare/Medicaid so it doesn?t compute.

You?ll definitely be psyched out paying $50 tax to get $25 back

Egads, you?re right, Jon. When I hit the post button I had an uneasy feeling that there was a scandal re the UHC exec in the recent past. All I can say is that at least one can ?fire? UHC, which I did for a while not from moral outrage but due to low reimbursement. Then I rehired them again a couple years later when they shaped up. Tough to do this with single payer.

Bert......I was just agreeing with you. Happy belated birthday...wanted to meet you in DC...todd

Thanks Todd. I'm slow sometimes.

No, you will not see that, because it is illegal (I believe) to deny care to Medicaid patients at the ED. But, that doesn't mean there isn't a shortage of care. If there were equal and good access to care, then a Medicaid patient could go to a competent doctor (in his or her field). But, they can't. Because the private doctors won't take them.

And, even if a Medicaid patient wants to pay cash, they can't.

In IL, Medicaid pays less for 99215 than 99214, I would NEVER use 99215 with them.

They don't go to the hospital to die, that's why they are not stacked up.. But measures of health outcome are worse in underserved areas.

Preventive medicine IS actively avoided. They will go to the ER for silly stuff that would have been much cheaper to deal with in the office and just not pay the bill. "You can't get blood from a turnip."

Most hospitals have tax exempt status which means they avoid paying property taxes, which are passed on to you. Insurances balk at paying increasingly higher rates to some hospitals so your "sneaky but efficient" method is neither. Property taxes are the sneakiest because they receive the least review. This is the way it was done 30 years ago, but with the ratcheting down of health care payments even hospitals are squeezed. OR they go to the county hospital which might provide free care. Again going to the taxes. Damned if you do, Damned if you don't. Overall poorer health care and they wind up completely unable to work and causing further drain on society. It's cheaper to provide health care for the populace from the beginning than play games. The number one cause of bankruptcy is medical care, and those bills won't get paid either.

I thought I remembered him getting a billion dollar bonus. When I googled I came up with this from Forbes:
http://www.forbes.com/static/pvp2005/LIRRI3M.html
Which states in a 5 (200-2005) year period his compensation was $342,284 thou(sands) Does that mean 342 BILLION? What was that about $20 Mil?
Fines of $600 mil were chump change if I am reading that right.

Medicare loves to pay for things that are not especially useful... like your annual "wellness exam". Then, they don't want to pay for things that are, like vaccinations. It is "Medical Theater", that sounds good on the campaign trail but is only a poor distortion of scientific medicine. They pay lots more for multiple "single problem visits" than for a single complex visit that is respectful of the time of patient and provider. And on and on. My best decision, medically, was to Opt out, by a long shot. To quote e.e.cummings, "There is some s*** I will not eat."

David, what is the reimbursement from your insurers that you do take? Not specifics. And, are you able to have a full practice without Medicaid/Medicare?

@David
anyone lived in a pretty how town
(with up so floating many bells down)
spring summer autumn winter
he sang his didn't he danced his did

Women and men (both little and small)
cared for anyone not at all
they sowed their isn't they reaped their same
sun moon stars rain

e.e. cummings

Wow, cummings would have been on Medicaid. How could he make money on that?

He would be living in North Dakota where the reimbursement is 141% of medicare rates!!!

"One man's s*** is another man's silver."
me-sort of

My practice is about 38% medicare but it would be a tough go without them in the mix.

See, you are better than E. E. Cummings.

No, and a lot more boring, never had the pleasure to hang with Pablo Picasso.
And David, my intent is not to belittle your practice, if I could do what you are doing I would, but I do not possess enough magnetism to convince my medicare patients to pay out of pocket to see me, I think they would go to a provider that accepts medicare.
But I have never really pushed the envelope either.

Our practice is pretty anachronistic by modern standards as far as I can tell. We don't have contracts. Consequently, Bert, I really don't know how to answer the first part of your question. As far as being busy, we don't try to see 20 patients a day. We can't really accommodate all applications to join our practice and need to limit our practice somewhat.

We opted out about 10 years ago. The patients that were with us then have been offered a deal; if they were medicare then or have aged into it, we are VERY liberal about our expected reimbursement. Newcomers are charged the usual and customary. Honestly, the physician charge component of medical care costs for primary care is not normally that big a problem.

When we opted out several years ago, I thought we were going to suffer a significant economic hit, but we deemed it worth while anyway. Strangely, that just did not happen. Our practice income actually rose slightly.