starting a practice and reimbursement schedule

[focus1979]

So I've been thinking about opening a practice with a family member who is also a psychiatrist in Georgia some day. It would be your typical practice(med mgt focused, therapists on staff). We would also both do suboxone. General adult psychiatry. Down the road we would possibly add things like other prescribers(psych nps, in house testing, groups, etc), but not initially.

My main questions center around reimbursements. This is not an area where we would have many self-pay patients, so our income would be entirely dependent on a few codes basically, mostly 90792 and 99214+90833 and the therapy codes our therapists get. But I can't find those anywhere for psychiatrists. I can't even find the current national medicare code structure.

1) For people out there in private practice, could you list the area you are in and what you are getting for these codes? What you are actually getting, not what you heard people get. Even if there aren't other private practice people in Georgia in here I would still like to know what people elsewhere are getting. I know in a few states I have been able to find online the codes are less than what medicare pays. That's not good.

2) Are these codes negotiable? For example could one board certified psychiatrist get 15% more than another in the exact same area for a 90792?

3) How do psych np codes typically compare on insurance plans to psychiatrist codes? Are they the same? 15% less?

My calculations suggest we would need to be averaging 175 dollars or so per reimbursement for intakes and 110-115 dollars per 99214/90833 f/u. Is this reasonable in Georgia? Or too optimistic?

thanks in advance.

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[Doctor Bagel]

I could be totally wrong, but I thought there was something where people actually can't reveal how much they're getting reimbursed by insurance companies. I think Medicare rates are publicly posted somewhere, though. There's probably some way to extrapolate actual insurance payments from posted rates on providers' websites.

I suspect regardless of the location, you can do cash only for Suboxone.

 

[clusterF]

So I've been thinking about opening a practice with a family member who is also a psychiatrist in Georgia some day. It would be your typical practice(med mgt focused, therapists on staff). We would also both do suboxone. General adult psychiatry. Down the road we would possibly add things like other prescribers(psych nps, in house testing, groups, etc), but not initially.

My main questions center around reimbursements. This is not an area where we would have many self-pay patients, so our income would be entirely dependent on a few codes basically, mostly 90792 and 99214+90833 and the therapy codes our therapists get. But I can't find those anywhere for psychiatrists. I can't even find the current national medicare code structure.

1) For people out there in private practice, could you list the area you are in and what you are getting for these codes? What you are actually getting, not what you heard people get. Even if there aren't other private practice people in Georgia in here I would still like to know what people elsewhere are getting. I know in a few states I have been able to find online the codes are less than what medicare pays. That's not good.

2) Are these codes negotiable? For example could one board certified psychiatrist get 15% more than another in the exact same area for a 90792?

3) How do psych np codes typically compare on insurance plans to psychiatrist codes? Are they the same? 15% less?

My calculations suggest we would need to be averaging 175 dollars or so per reimbursement for intakes and 110-115 dollars per 99214/90833 f/u. Is this reasonable in Georgia? Or too optimistic?

thanks in advance.

ONE BILLION DOLLARS!!!
Medicare rates are pretty easy, just google it. For example a 99213/99214 will pay probably 55/80 (that being about 80%). I think the 90833 pays about the same as the 99213. These are rough estimates based on recollection.

 

[honsano]

This site is helpful: https://ocm.ama-assn.org/OCM/CPTRelativeValueSearch.do?submitbutton=accept

You can't get solid numbers about insurance because there is so much variability such as the providers credentials, the need in the area, etc. You can ask someone in the area to see what they get, otherwise it is a tough find. Another thought, see if there are employment positions in the area you are looking and talk with them to see how much they reimburse per wRVU. Though you won't be a wRVU model, you can get an idea on how much they get for a code.

Do share if you end up pursuing this.

 

[PistolPete]

Do you guys think that Medicare keeps track of the % of your billing that is 99214, versus the national average? I've always been curious about this. For example, what if you see all the difficult cases in your area?

My other question: a 99214 requires 2 of the following 3: a detailed history, a detailed examination, and/or medical decision making of moderate complexity. What stops me from getting a detailed history and detailed exam on all my patients and a billing a 99214 for everyone? This is why I think medical decision making trumps all, even though the CPT manual might say otherwise.

 

[clusterF]

Do you guys think that Medicare keeps track of the % of your billing that is 99214, versus the national average? I've always been curious about this. For example, what if you see all the difficult cases in your area?

My other question: a 99214 requires 2 of the following 3: a detailed history, a detailed examination, and/or medical decision making of moderate complexity. What stops me from getting a detailed history and detailed exam on all my patients and a billing a 99214 for everyone? This is why I think medical decision making trumps all, even though the CPT manual might say otherwise.

There is no such thing as "medicare" when it comes to who is paying you locally. CMS farms all this out to smaller companies like palmetto, noridian etc. They all work differently.

 

[hamstergang]

What stops me from getting a detailed history and detailed exam on all my patients and a billing a 99214 for everyone?

Do they audit charts and ever say, "you didn't need to ask that, you only did it to up charge, so we're taking our money back," or does that not happen?

 

[focus1979]

ONE BILLION DOLLARS!!!
Medicare rates are pretty easy, just google it. For example a 99213/99214 will pay probably 55/80 (that being about 80%). I think the 90833 pays about the same as the 99213. These are rough estimates based on recollection.

I did google it and it can't find the Medicare rates listed anywhere.

If the Medicare 99214 alone pays 80 bucks I would be very very happy.

 

[Doctor Bagel]

Do you guys think that Medicare keeps track of the % of your billing that is 99214, versus the national average? I've always been curious about this. For example, what if you see all the difficult cases in your area?

My other question: a 99214 requires 2 of the following 3: a detailed history, a detailed examination, and/or medical decision making of moderate complexity. What stops me from getting a detailed history and detailed exam on all my patients and a billing a 99214 for everyone? This is why I think medical decision making trumps all, even though the CPT manual might say otherwise.

That's why you code based on time, which I think is honestly not not-legit with most psych patients.

 

[PistolPete]

That's why you code based on time, which I think is honestly not not-legit with most psych patients.

If you code EM plus psychotherapy add-on, you can only bill the psychotherapy add-on portion based on time. The EM portion (i.e. 99213 or 99214) must be based on "key elements," hence my question above.

 

[Shikima]

Billing by time has gone by the wayside I believe for more medical/factual based documentation.

 

[milesed]

The link above shows 99213 paying $68 and 99215 paying $101 for non-facility in our area. That's spot on.

 

[hamstergang]

I thought you could bill by time if more than half the time was spent on counseling?

 

[Shikima]

I thought you could bill by time if more than half the time was spent on counseling?

Correct and True. 908xx codes are based on time. The traditional E&M codes aren't unlike years past prior to the switch.

 

[TexasPhysician]

I thought you could bill by time if more than half the time was spent on counseling?

Yes, you can.

Based on clinical situation and time in appt, bill by whichever method pays more.

 

[TexasPhysician]

Billing by time has gone by the wayside I believe for more medical/factual based documentation.

It is still alive and well. The same 99*** codes can be met by time or points. Usually the points method is better because you can include therapy add-ons. Time coding does not allow therapy add-ons.

 

[TexasPhysician]

I could be totally wrong, but I thought there was something where people actually can't reveal how much they're getting reimbursed by insurance companies.

I suspect regardless of the location, you can do cash only for Suboxone.

Correct. Revealing reimbursements is against insurance contracts and gets you cut by panels.

It is not legal to do cash-only suboxone at the same location where you take insurance. Insurance companies would claim it is in-network and covered by the contract.

 

[PistolPete]

Correct. Revealing reimbursements is against insurance contracts and gets you cut by panels.

It is not legal to do cash-only suboxone at the same location where you take insurance. Insurance companies would claim it is in-network and covered by the contract.

So how do you find out which insurance panels are worth signing up for? Having unofficial conversations with peers who reveal their rates?

 

[TexasPhysician]

So how do you find out which insurance panels are worth signing up for? Having unofficial conversations with peers who reveal their rates?

This is one of many reasons that I have moved to cash only.

Apply to every insurance company. During the review process, they will reveal their rates. Then you haggle with them if you can. Then select the insurances you wish to take. They will have you sign that you agree not to reveal the rates.

 

[MrWonderful]

What are the typically best paying insurances?

 

[Shikima]

Each locality is different.

 

[Doctor Bagel]

So how do you find out which insurance panels are worth signing up for? Having unofficial conversations with peers who reveal their rates?

Kind of. You can also look and see if they post their rate schedule on their website to give you a starting point. Seeing who they accept also probably tells you who is the best to work with. In my community, I've heard of 3 who are OK and a few who are notoriously horrible.

 

[smalltownpsych]

I don't know how United Healthare pays since the hospital negotiates our rates, but I can tell you they are the worst at trying to micromanage what I can or can't do with my patients. They also won't let the office staff do much of anything, they want us to waste our time on the phone with them because they definitely don't have to pay for that time. Also, they are good at turning down claims if they find any little flaw in the billing and then they have the shortest timeline to rectify before it is too old to pay. That last part I found out from my wife who does medical billing here at the hospital. I think she said it was four months to resolve any issues from the date of service. Compare this to medicare who gives a year from last submission of a correction.

 

[Doctor Bagel]

I don't know how United Healthare pays since the hospital negotiates our rates, but I can tell you they are the worst at trying to micromanage what I can or can't do with my patients. They also won't let the office staff do much of anything, they want us to waste our time on the phone with them because they definitely don't have to pay for that time. Also, they are good at turning down claims if they find any little flaw in the billing and then they have the shortest timeline to rectify before it is too old to pay. That last part I found out from my wife who does medical billing here at the hospital. I think she said it was four months to resolve any issues from the date of service. Compare this to medicare who gives a year from last submission of a correction.

I've heard nothing but bad things about them.

 

[OldPsychDoc]

I've heard nothing but bad things about them.

The Evil Empire.

 

[smalltownpsych]

I've heard nothing but bad things about them.

The Evil Empire.

Yup, just wanted to do my small part to keep the negative publicity going. I really don't like those guys. I cringe when I talk to them on the phone and they offer up the contrived polite and respectful tone while I am trying to jump through their friggin hoops just so that my patients or the hospital doesn't get stuck with an unpaid claim. One example is needing a preauthorization for 60 minute sessions for treatment of PTSD. They have to pay for it because it is the standard of care but they make me justify it to them. None of their damn business how my patient was traumatized. Bastards!
Can I say that on here?

 

[PistolPete]

Wow, that sounds awful. No wonder half of all psychiatrists in the US don't take insurance...