Monday, March 15, 2010

Melissa Young, MD: How much am I getting paid?

At my former job, as an employed physician, I didn’t really know how much I was getting paid for each patient encounter. Yes, we had a meeting with our billing department. I’m not quite sure why, since the bottom line was well, it is what it is, and the answer to any question was “I’ll run a report.” Yes, a report I rarely ever saw.

Oh, yes, I saw how much was charged each month and how much was collected and how much was written off. But I wanted more information. I asked on numerous occasions for a breakdown of how much we were getting paid for each E&M code. I asked for a breakdown of our contracted rates with each payer. Apparently, they could not tell me what the rates were per se, but they could tell me what percentage of Medicare “since that’s public.” Sure, they could. But they didn’t.

So when I ventured off on my own, and submitted my change of address and change of TIN to the insurance companies, I did so without really knowing what my contracted rates were and without knowing whether they would or had changed. Probably unwise on my part. But at the time, my only concern was being credentialed and getting paid something. Anything.
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So I mentioned in my last post that my husband is my biller. And he feels I am not being paid what I should be. I figured, I will get the practice up and going and look at the numbers and see what payers are paying what, and then go back and renegotiate as needed. Well, he got tired of waiting for me, so he spoke to someone who negotiates insurance contracts. He said she gasped when she heard what I was being paid. Apparently, not enough.

But she needs a copy of my contracts. And guess what. I don’t have a copy of any but one. Yes, again, foolish on my part. I need to know at the very least, when they expire, because if we are going to renegotiate, we need to do so around the time I am supposed to re-up.

I am going to have to have someone (me, my husband, my staff) call the insurance companies and ask for a copy of my contract. I wonder how cooperative they will be. It’s always a challenge getting a human on the phone. We have all spent many frustrated hours being transferred, getting disconnected and trying to get these stupid voice activated systems to work. I’d swear they do it on purpose. My secretary thinks they listen in on her and laugh as she swears at the phone in frustration. I have a sinking feeling that getting these contracts is going to be like pulling teeth.


  1. Great article Melissa! Believe it or not your situation is actually fairly common. You provide a great service, put your patients first and hope your billing is being taken care of correctly. Prior to your husband billing for you it does not appear that it was and he's right to start now with finding out where you stand and where you should be based on your specialty.

    As far as the difficulty you will face obtaining a copy of your contract that will solely depend on the health plans you are contracted with. I own a billing service and one of the providers I bill for requested a copy of her contract 3 times before receiving it 3 weeks after the last request. When you, your husband or secretary contact the insurance companies be sure to go through the Provider Relations departments and ask who the dedicated rep is for your area and their direct contact information. I hope this information is helpful and I would love to read your opinion on healthcare reform. Its great to hear directly from those impacted.

    Melissa Turner, CEO - CPMB
    Mainstream Services Inc.

  2. Thank you for your advice. I have to say, it is nearly impossible to even find the correct phone number. When we call physician services, we are sucked into those horrible automated telephone services that ask for the patient's information. Well, we're not calling about a patient, so now what? we're going to have to do a little detective work.

  3. Dr Young-

    This link of phone numbers includes provider relation numbers and may help you and your husband with getting contract information - it was published by UMDNJ and it was accurate last time we used it at my practice.

    Anonymous Biller

  4. Thanks, Biller!

  5. Ron @ www.rmk123.comMarch 23, 2010 at 2:34 PM

    Sounds like you are moving in the right direction! Passing along a few pointers to arm yourself with during the renegotiation stage even though it appears that you have someone negotiating on your behalf.

    1) Bear in mind that unless you are a large volume provider in your area, you may find it challenging to increase the rate above your geographical norm. One way to overcome this is to bring up something you do better in your practice than a competitor. For example - you could be expanding your hours of operation, increasing your patient flow and be a more precise follower of clinical guidelines.

    Understand and then prove your worth to your payers.

    2) Look at the BC/BS rates as a baseline especially if you like what you see.

    3) Start tracking the top 20 to 30 CPT codes that comprise 80 to 90 percent of your business. If the income from those codes is decreasing, check your contract. If you notice that a new contract includes a decrease in reimbursements under your key codes, bring it to the attention of your health plan representative. You may get it changed.

    4)Dig into the health plan's fee schedule. What you may see is that some of the codes you use the least have been increased to 150 percent of the Medicare rate. However, the codes you use the most are at 105% of Medicare plus they're decreased from the prior contract! It averages out higher but actually means less revenue for your practice.

    5)Watch out for companies who base their rates on the prior year's Medicare fee schedule instead of upgrading the fees to the current schedule.