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.
Showing posts with label payers. Show all posts
Showing posts with label payers. Show all posts
Monday, March 15, 2010
Monday, December 21, 2009
Health reform on the horizon
Is it really possible? Will the Senate actually pass a healthcare bill this week?
It looks like they will pass the legislation on Christmas Eve, the WSJ reports. The Senate’s bill would extend health insurance coverage to some 30 million Americans, create a national insurance exchange, and include subsidies for low- and middle-income to comply with an insurance mandate.
Read more
It also is tough on insurers, barring them from denying coverage to children with pre-existing conditions (and adults with pre-existing conditions starting in 2014).
But it also includes cuts of $480 billion over a decade in payments to Medicare providers.
Meanwhile, new, last minute provisions hiked the cost of the bill up by $23 billion to $871 billion over ten years. Reasons for the increase include expanding the small business tax credit and deleting provisions for increase payment rates under Medicare.
Senators scrapped a one-year fix to the Medicare payment rates because doctors don’t just want a temporary fix, Reid told MedPage Today. This leaves the door open for Congress to permanently repeal the flawed SGR-based payment formula. Last week, the House and the Senate passed two-month fixes, delaying the cuts until March 2010 or until a more permanent solution can be passed.
The Senate’s healthcare bill does raise some revenue by increasing the payroll tax on higher income individuals and families (from 0.5 percent to 0.9 percent for individuals making $200,000 and families making $250,000), according to HealthLeaders Media.
And unsurprisingly, the bill includes funding benefiting specific constituencies, inserted to clench certain lawmakers’ support, the NY Times reports, such as “victims of environmental hazards,” i.e. people exposed to asbestos from a mine in Montana – home state of Finance Committee chairman Sen. Max Baucus.
It looks like they will pass the legislation on Christmas Eve, the WSJ reports. The Senate’s bill would extend health insurance coverage to some 30 million Americans, create a national insurance exchange, and include subsidies for low- and middle-income to comply with an insurance mandate.
Read more
It also is tough on insurers, barring them from denying coverage to children with pre-existing conditions (and adults with pre-existing conditions starting in 2014).
But it also includes cuts of $480 billion over a decade in payments to Medicare providers.
Meanwhile, new, last minute provisions hiked the cost of the bill up by $23 billion to $871 billion over ten years. Reasons for the increase include expanding the small business tax credit and deleting provisions for increase payment rates under Medicare.
Senators scrapped a one-year fix to the Medicare payment rates because doctors don’t just want a temporary fix, Reid told MedPage Today. This leaves the door open for Congress to permanently repeal the flawed SGR-based payment formula. Last week, the House and the Senate passed two-month fixes, delaying the cuts until March 2010 or until a more permanent solution can be passed.
The Senate’s healthcare bill does raise some revenue by increasing the payroll tax on higher income individuals and families (from 0.5 percent to 0.9 percent for individuals making $200,000 and families making $250,000), according to HealthLeaders Media.
And unsurprisingly, the bill includes funding benefiting specific constituencies, inserted to clench certain lawmakers’ support, the NY Times reports, such as “victims of environmental hazards,” i.e. people exposed to asbestos from a mine in Montana – home state of Finance Committee chairman Sen. Max Baucus.
Friday, November 6, 2009
Congress to insurers: We're watching you
Regardless of whatever health reform makes its way out of Washington, it looks like Congress has its eyes on the insurance industry. Perhaps it was Cigna’s 93 percent profit jump in the third quarter?
House Speaker Nancy Pelosi called Cigna’s $329 million profit “stunning,” according to HealthLeaders Media. Similarly, Sen. Thomas Harkin on Wednesday brought up the insurance industry’s price increases to small businesses, citing a survey that showed average policies will increase 11 percent to 16 percent (and as much as 30 percent) annually in most states.
Read more
Harkin announced an investigation into the pricing practices of insurance companies that sell to small businesses. He also sent letters to the heads of Humana, UnitedHealth Group, WellPoint, and Aetna asking for information about how they determined insurance rates for small businesses and the percentage of premiums spent on medical care.
The House bill does try to address insurer profits with an amendment to overturn a long-standing act that has antitrust exemptions for the industry, as well as provisions to limit high charges. Insurance companies would also be barred from denying coverage for pre-existing conditions. Voting on the House bill (which the AMA, AARP, and MGMA have all thrown their support behind) is set to begin Saturday.
House Speaker Nancy Pelosi called Cigna’s $329 million profit “stunning,” according to HealthLeaders Media. Similarly, Sen. Thomas Harkin on Wednesday brought up the insurance industry’s price increases to small businesses, citing a survey that showed average policies will increase 11 percent to 16 percent (and as much as 30 percent) annually in most states.
Read more
Harkin announced an investigation into the pricing practices of insurance companies that sell to small businesses. He also sent letters to the heads of Humana, UnitedHealth Group, WellPoint, and Aetna asking for information about how they determined insurance rates for small businesses and the percentage of premiums spent on medical care.
The House bill does try to address insurer profits with an amendment to overturn a long-standing act that has antitrust exemptions for the industry, as well as provisions to limit high charges. Insurance companies would also be barred from denying coverage for pre-existing conditions. Voting on the House bill (which the AMA, AARP, and MGMA have all thrown their support behind) is set to begin Saturday.
Friday, September 18, 2009
Do payers support tort reform?
Lucien Roberts is an administrator and member of our advisory board. He had some comments about payers and tort reform, and the following post is his column.
Do payers support tort reform? On the surface, perhaps, but in the trenches, not at all. Here’s my litmus test.
You, dear doctor, are confronted in the exam room by a patient demanding a head MRI. Said patient went online last night and learned that headaches are the primary symptom of brain tumors. The MRI is not warranted by the patient’s history and physical. Further, the best practice clinical guidelines used by the payer do not support the MRI. You do not order the MRI, despite the patient’s protestations.
Six months later, the patient is diagnosed with a glioblastoma.
Read more
She is that one in however-many-thousands. She sues you, and your career as you know it will never be the same. You will order more MRIs, for discretion will never again be the better part of your valor.
Where was the payer as this unfortunate case unfolded? Good question. If the payer truly supported tort reform, it would stand both behind and beside you in this scenario. The payer would affirm that your actions were clinically appropriate and ask that the lawsuit be dismissed. After all, you were following the dictates of the payer — and not the insistence of the patient — in not ordering the MRI.
Unfortunately, this scenario plays out every week. Patients are not widgets, and even the broadest clinical practice guidelines will not catch every anomaly. Until payers stand behind their clinical practice guidelines and beside physicians, they are not substantively supporting tort reform. That is my solid opinion.
To their credit, the board of directors of the America’s Health Insurance Plans (AHIP) proffered a December 2008 proposal that included the following affirmation:
“The nation should also explore approaches for replacing our medical liability system with a new dispute-resolution process that is fair to patients and protects physicians against liability if they follow best-practice standards.”
AHIP estimates potential savings of $45 billion over the next five years. Unfortunately, their press releases in recent months have not emphasized, much less mentioned, this key element. This last statement is important. If AHIP truly supports tort reform as a critical piece of the healthcare reform puzzle, it must keep the dialogue on the front burners.
How many payers in your market will stand behind you when something bad happens while you follow their clinical practice guidelines? I suspect the answer is “zero,” and that is most unfortunate. Best practice guidelines, in the absence of payer support of tort reform, are but cloaks to hide payers from patient litigation. They guide and restrict the way you practice, but do nothing to protect you.
If AHIP and its members want to make a real statement about tort reform, they must replace their rhetoric with action. Now. Give a backbone to best practice guidelines and have the courage to support physicians who follow them. So, do payers truly support tort reform? Not yet, but this would be a great way to start.
Lucien Roberts, III, MHA, FACMPE, is executive director of Neuropsychological Services of Virginia. He also consults with medical groups and health systems in areas such as compliance, physician compensation, negotiation, strategic planning, and billing/collections. He may be reached at lucien.roberts@yahoo.com.
Do payers support tort reform? On the surface, perhaps, but in the trenches, not at all. Here’s my litmus test.
You, dear doctor, are confronted in the exam room by a patient demanding a head MRI. Said patient went online last night and learned that headaches are the primary symptom of brain tumors. The MRI is not warranted by the patient’s history and physical. Further, the best practice clinical guidelines used by the payer do not support the MRI. You do not order the MRI, despite the patient’s protestations.
Six months later, the patient is diagnosed with a glioblastoma.
Read more
She is that one in however-many-thousands. She sues you, and your career as you know it will never be the same. You will order more MRIs, for discretion will never again be the better part of your valor.
Where was the payer as this unfortunate case unfolded? Good question. If the payer truly supported tort reform, it would stand both behind and beside you in this scenario. The payer would affirm that your actions were clinically appropriate and ask that the lawsuit be dismissed. After all, you were following the dictates of the payer — and not the insistence of the patient — in not ordering the MRI.
Unfortunately, this scenario plays out every week. Patients are not widgets, and even the broadest clinical practice guidelines will not catch every anomaly. Until payers stand behind their clinical practice guidelines and beside physicians, they are not substantively supporting tort reform. That is my solid opinion.
To their credit, the board of directors of the America’s Health Insurance Plans (AHIP) proffered a December 2008 proposal that included the following affirmation:
“The nation should also explore approaches for replacing our medical liability system with a new dispute-resolution process that is fair to patients and protects physicians against liability if they follow best-practice standards.”
AHIP estimates potential savings of $45 billion over the next five years. Unfortunately, their press releases in recent months have not emphasized, much less mentioned, this key element. This last statement is important. If AHIP truly supports tort reform as a critical piece of the healthcare reform puzzle, it must keep the dialogue on the front burners.
How many payers in your market will stand behind you when something bad happens while you follow their clinical practice guidelines? I suspect the answer is “zero,” and that is most unfortunate. Best practice guidelines, in the absence of payer support of tort reform, are but cloaks to hide payers from patient litigation. They guide and restrict the way you practice, but do nothing to protect you.
If AHIP and its members want to make a real statement about tort reform, they must replace their rhetoric with action. Now. Give a backbone to best practice guidelines and have the courage to support physicians who follow them. So, do payers truly support tort reform? Not yet, but this would be a great way to start.
Lucien Roberts, III, MHA, FACMPE, is executive director of Neuropsychological Services of Virginia. He also consults with medical groups and health systems in areas such as compliance, physician compensation, negotiation, strategic planning, and billing/collections. He may be reached at lucien.roberts@yahoo.com.
Monday, July 13, 2009
Multiple payers buy in on medical homes
Are the stars aligning for a robust medical home movement?
Pilot projects for the patient-centered medical home being launched in four states have what apparently most — if not all — other efforts lacked: involvement by multiple insurers, according to an American Medical News story.
Under the medical home model, patients have a central primary-care physician directing their care (aimed at improving quality of care and lowering costs), and docs are paid extra for coordinating care. Read more about the model and preventive care in a recent Physicians Practice article.
Read more
The idea isn’t new, but has been gaining momentum. What’s needed for widespread adoption? Reimbursement reform and electronic records, pediatrician and medical home proponent W. Carl Cooley tells AMNews.
Are these latest pilots the answer? Here, the plans and the docs will track patient outcomes, sending the data to be studied and published, which shed some light on how much money the model can save.
What do you think of the medical home model? Is this development signaling payer buy-in? Will it work?
Pilot projects for the patient-centered medical home being launched in four states have what apparently most — if not all — other efforts lacked: involvement by multiple insurers, according to an American Medical News story.
Under the medical home model, patients have a central primary-care physician directing their care (aimed at improving quality of care and lowering costs), and docs are paid extra for coordinating care. Read more about the model and preventive care in a recent Physicians Practice article.
Read more
The idea isn’t new, but has been gaining momentum. What’s needed for widespread adoption? Reimbursement reform and electronic records, pediatrician and medical home proponent W. Carl Cooley tells AMNews.
Are these latest pilots the answer? Here, the plans and the docs will track patient outcomes, sending the data to be studied and published, which shed some light on how much money the model can save.
What do you think of the medical home model? Is this development signaling payer buy-in? Will it work?
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