2023 Medicare cuts

[Creflo]

Did we end up with a 2 or 2.5% cut in medicare payments for 2023? I'm surprised I haven't seen a lot of recent headlines about this. This seems like a slap in the face considering recent inflation.

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[heybrother]

My memory is that you have a very specific practice type that caters to Medicare but is cash only for the rest. We'll all have to continue to evaluate our relationship with payors. The simple truth is that as frustrating as Medicare cuts are I have plural payors who reimburse less than Medicare. I've spent a lot of time thinking about large payors this years as I shop at stores and restaurants that are raising their prices. Meanwhile our reimbursement is mostly fixed except for uncovered services and cash pay patients. Its probably part of why you see so many scammy DPMs looking for cash pay services and garbage like wart microwaves. I think a lot of podiatrists through time have viewed Medicare as a "good payor". I pulled some Medicare data for another thread. With the exception of E&M - it appears to me that Medicare fee schedule rates have either decreased or best case scenario simply remained stagnant through time. Depending on where you start from a plantar fascial injection has been about $50-55 for 20 years.

I just found out I was accepted to an IPA. I'm waiting on one set of fee schedules to determine how worthwhile this process will be. Theoretically, assuming the payor doesn't tell us to screw off, we'll dramatically increase our reimbursement from one of our payors. Interestingly, I will have to change (increase) our fee schedules for all of our E&M codes if the values I'm being told are true..

I did better than I've ever done this past year but every day is another battle to stay in business and try to get what we're worth. The difference in fee schedules between good and bad insurance is just becoming absurd - like 100% of Medicare between a good payor and a bad payor.

 

[Creflo]

Yes medicare only and cash for rest.

 

[Feli]

Happens with dems at the helm all the time:

1) Medicare Rvu conversion fees cut to give more ppl coverage (propose some crazy huge cut, then docs are "happy" with only 2% or 3% haircut)...

2) ...but at the same time, their economy is usually also in the toilet, so supplies, employees, etc are cheaper too. 2023 is gonna get pretty lean for many industries and the market might look pretty red. Stay tuned.

It's too bad... docs are an easy target to take $ from since they're a small portion of the population (aka voters), they dont stick together well, and they'reviewed as "rich." Hospitals have ways of working around cuts in this area or that one.

Be glad DME went up, though. If you want to succeed in PP, you always want good payers and/or little area competition (relative to area pop). Those things are unfortunately more important than talent or hard work. The convo was same 10-12yr ago when I came out and was looking into solo PP. Fun times

 

[PatchAdamsFan]

Medicare RVU rates for E/M codes have gone up over 30% from 2020 levels, as I'm sure everyone is aware. That is significant. I think it's important to specify what we're talking about: procedural codes. E/M changes don't just benefit PCP incomes...

 

[Boba Foot]

Happens with dems at the helm all the time

OK bro, and your alternative is the party that wants to eliminate Medicare altogether.

 

[heybrother]

The E&M change was appreciated as was the decrease in documentation. From 2020 to now Medicare's $ value for a 99213 increased 17% (I'm listing this one because it was to my memory the largest of the increases). However, my memory is the change was supposed to be budget neutral across all specialties. In fact, if you looked around you saw a variety of codes going slightly up and slightly down. 11750 went up $4. 28232 went down $4. There was definitely a give and take. In prior years when the "% decrease" values came out I'd try to calculate/guess what things would be worth the next year but you really just have to wait for the new fee schedule.

Unfortunately, none of the major commercial insurers use Medicare's values or RVU as the basis for reimbursement to PP docs. A Medicare 99213 is more valuable than a BCBS, Cigna, United, Aetna 99213. A Medicare 11056+11720 > BCBS 99214. These sort of events will continue to produce the hilarious SDN banter that is hospital and PP going after each other and by that I entirely mean hospital people making fun of PP people.

 

[heybrother]

OK bro, and your alternative is the party that wants to eliminate Medicare altogether.

My partner regularly says something to the effect of "George Bush signed Medicare Advantage into law.

 

[bloxxeeey]

OK bro, and your alternative is the party that wants to eliminate Medicare altogether.

Would you prefer a country where everyone had access to health care, that would destroy the system and our job market. Look at how terrible people are treated in countries with health care covered for everyone, they pay more for it and have worse outcomes. They literally have boards to determine whether you get access to treatment or not, imagine a board or company saying they wouldn't give you insulin or an incision and drainage when you have an infection and needed it.

 

[Boba Foot]

Would you prefer a country where everyone had access to health care, that would destroy the system and our job market. Look at how terrible people are treated in countries with health care covered for everyone, they pay more for it and have worse outcomes. They literally have boards to determine whether you get access to treatment or not, imagine a board or company saying they wouldn't give you insulin or an incision and drainage when you have an infection and needed it.

You know that Medicare isn’t the same thing as universal healthcare right? Not sure why this launched you into the ol’ universal healthcare subject…

But since you wanted to go there… yes, I do prefer a situation in which every American has access to the health care that they need. I would think that most decent human beings would prefer all other human beings to have access to health care that they need. Isn’t life an inalienable right?

But then you have people that watch Fox News and eat up the BS about “death panels”. They like to somehow think that our healthcare system is better than just about every other first world country even though our costs are much higher and healthcare quality is worse. Good for insurance companies who like to screw us and patients over by constantly denying claims and cutting reimbursements; bad for us and bad for patients.

Interesting you mentioned insulin though. Do you know who blocked a $35 cap on insulin?

 

[Scrantonicity]

You know that Medicare isn’t the same thing as universal healthcare right? Not sure why this launched you into the ol’ universal healthcare subject…

But since you wanted to go there… yes, I do prefer a situation in which every American has access to the health care that they need. I would think that most decent human beings would prefer all other human beings to have access to health care that they need. Isn’t life an inalienable right?

But then you have people that watch Fox News and eat up the BS about “death panels”. They like to somehow think that our healthcare system is better than just about every other first world country even though our costs are much higher and healthcare quality is worse. Good for insurance companies who like to screw us and patients over by constantly denying claims and cutting reimbursements; bad for us and bad for patients.

Interesting you mentioned insulin though. Do you know who blocked a $35 cap on insulin?

Why isn't food free? Why isn't heating/air free? Shouldn't everyone have a free alarm system at their house too? I mean the right to life is inalienable for God's sake!

 

[HardRoadPaved]

Why isn't food free? Why isn't heating/air free? Shouldn't everyone have a free alarm system at their house too? I mean the right to life is inalienable for God's sake!

At least the right to having nails trimmed every 61 days is protected for at-risk individuals... what more do you want?!

 

[Adam Smasher]

lock this thread

edit: if 100% of the commenters in this forum can't all agree on glaringly obvious statements like "podiatry is a saturated profession" I don't know how we can debate a 15 year-old issue like health care reform

 

[bloxxeeey]

You know that Medicare isn’t the same thing as universal healthcare right? Not sure why this launched you into the ol’ universal healthcare subject…

But since you wanted to go there… yes, I do prefer a situation in which every American has access to the health care that they need. I would think that most decent human beings would prefer all other human beings to have access to health care that they need. Isn’t life an inalienable right?

But then you have people that watch Fox News and eat up the BS about “death panels”. They like to somehow think that our healthcare system is better than just about every other first world country even though our costs are much higher and healthcare quality is worse. Good for insurance companies who like to screw us and patients over by constantly denying claims and cutting reimbursements; bad for us and bad for patients.

Interesting you mentioned insulin though. Do you know who blocked a $35 cap on insulin?

I prefer a situation where Americans continue to receive what they work hard for like we do now. When I was a student and got sick I didn't go to the doctor or hospital because even with the school's insurance I couldn't pay the copay. That was smart money management by me, why should other's get the pass to go use these benefits with no repercussions, with no sacrifice. Insulin shouldn't be capped because these companies need to make money, it's the foundation of our capitalistic society. It's the reason we grow and the reason we have the highest quality of life in the world.

 

[heybrother]

I recommend a little reading:

-Perhaps 10 minutes on the history of insulin. “Insulin does not belong to me, it belongs to the world.” - the inventor of insulin who sold the patent on it for $1.

-Something closer to home: how colchicine which has been in existence for like 1400 years went from being 10 cents a pill to $5 over night thanks to a drug company and the FDA.

Colchicine price increase: how drug companies are taking advantage of the FDA's Unapproved Drugs Initiative.

A drug called colchicine is all that keeps some 2 million American gout patients from suffering debilitating pain in their toes, elbows, wrists, and...

slate.com

-Or how non-profit hospitals do everything they can not to provide charity care even though they receive generous tax breaks.

Big Hospitals Provide Skimpy Charity Care—Despite Billions in Tax Breaks

Nonprofit medical institutions get large federal benefits in exchange for providing support to their communities but often lag behind their for-profit peers, a Wall Street Journal analysis shows.

www.wsj.com

Many Hospitals Get Big Drug Discounts. That Doesn’t Mean Markdowns for Patients.

Through a government program aimed at helping low-income patients, some hospitals buy medications at reduced prices. They can sell them to patients and their insurers for much more.

www.wsj.com

What would single payor be like? I don't know. I do know that United, Humana, and Aetna all pay less than Medicare currently does. Cigna and S&W currently pay a tiny premium over Medicare. Perhaps under single payor all the above rates will seem like a dream and I never knew how good I had it. But anyone sitting here acting like its "so great" is just kidding themselves. Insurance companies, hospitals, and drug companies have an amazing racket right now. They have all the money. They have all the arbitrage. Talking about "capitalism" is just empty conservative virtue signaling. We're pawns. If you're going to be a pawn at least be a pawn who understands your place in the world. You do hard work. The people who invented insulin and other drugs DECADES ago did hard work. Martin Shreli did not do hardwork.

Daraprim was invented in 1953. Martin Shkreli increased the price of a pill in 2015 from $13.50 to $750 because "capitalism".

A line I heard forever ago was that Communism/Socialism failed because "it wasn't actual socialism". We can argue what all those things mean, what capitalism means, but I don't think the US healthcare system is actually what most conservative people think of when they think capitalism. No competition, no transparency, regulatory capture. Back to the start of the paragraph, a liberal person would probably say that's exactly what capitalism is.

 

[Bored Snorlax]

Would you prefer a country where everyone had access to health care, that would destroy the system and our job market. Look at how terrible people are treated in countries with health care covered for everyone, they pay more for it and have worse outcomes. They literally have boards to determine whether you get access to treatment or not, imagine a board or company saying they wouldn't give you insulin or an incision and drainage when you have an infection and needed it.

Isn't that what everyone puts on their personal statement to save lives and help heal the suffering?

I'd rather be broke and live the rest of my life in poverty than turning away a single patient b/c they can't afford access to care.

 

[heybrother]

Isn't that what everyone puts on their personal statement to save lives and help heal the suffering?

I'd rather be broke and live the rest of my life in poverty than turning away a single patient b/c they can't afford access to care.

Let me know in 6-7 years if the clinic you work at sees Medicaid.

 

[Adam Smasher]

OK since we're not locking this, I'll chime in. I do accept medicaid which has been a mixed bag.

You hear about people who need $800k worth of emergency spine surgery and then get stuck with a bill because it turns out the hospital was out-of-network, and their surgeon just shrugs "I only work here," and they end up getting hounded by collection agencies, and I truly feel terrible for them.

On the flip side, you come to podiatry clinic where public aid patients want free everything. Free shoes, free gauze, free moisturizing lotion, free triple antibiotic that you can buy at the dollor general. Medicaid pays for their transportation to their appointment with me, so they are free-riders in a very literal sense. I sometimes consider myself a welfare recipient by proxy. The harm is that these kinds of appointments block out patients with injury/disease who really need a doctor's attention. So yes, I have seen a glimpse of universal healthcare, and it is a peculiar sight.

I understand Germany's health care system is pretty good, but that may be because it's full of Germans

 

[Weirdy]

I'd rather be broke and live the rest of my life in poverty than turning away a single patient b/c they can't afford access to care.

Its different when you have a spouse and kids to feed, as well as 3-5k a month in debt repayment.

 

[DYK343]

I am an independent voter. I refuse to vote solely on party lines. Thats for sheeple. I vote both R and D in every election based on policies the candidates have that I support. One thing I will always vote in favor of is food, shelter, and medicine. Its the backbone of a 1st world country.

Would you prefer a country where everyone had access to health care,

yes, I would.

Why isn't food free?

Foodstamps exist.

Access to food, shelter, and medicine should be at the foundation of a 1st world country. Yes, people will abuse the system. You're free to post as many cases of abuse as you want. But its something IMO every American should have a right to have.

Would you prefer a country where everyone had access to health care, that would destroy the system and our job market. Look at how terrible people are treated in countries with health care covered for everyone, they pay more for it and have worse outcomes. They literally have boards to determine whether you get access to treatment or not, imagine a board or company saying they wouldn't give you insulin or an incision and drainage when you have an infection and needed it.

Taking 1 example and extrapolating it as an all means for all countries/systems. There are countries (Germany, as stated above) and the nordic states do a pretty good job. Canada does not.

If the United states was able to figure out a logical way for Medicare for all it would benefit our society. It would take years of a two party system going back and forth to get it right. One shouldnt get denied lifesaving cancer treatment because they work 9-5 in a factory and cant afford it.

Personal example of how i have seen the current system fail. Grew up straight middle class. 1 family vacation a year. Middle of the pack house in a decent neighborhood, etc, etc. Had a family member get pretty sick with cancer when I was a kid. Was in and out of the hospital for about a year and had 5-6 years of treatment. We had some form of BCBS insured through my father who worked as a shipping department manager at a factory. My mom taught 4th grade. We exceeded the threshold that insurance would pay pretty quickly. They took our family savings, checking, 401k/retirement. My parents lost everything they had saved in their early/mid 40s. Completely cleaned out all because someone needed lifesaving treatments and insurance wouldnt pay beyond a certain amount. I know. Boohoo. Poor me. But that shouldnt happen to Americans. The system isnt right and I've seen its failures with my own eyes.

There are a couple dirty communist liberal states who have aggressively expanded medicaide. They make it very easy for people under a certain income threshold to get on medicaide insurance and aggressively increased the amount of health centers that accept medicaide (Community Health Centers). The cost savings was significant and the programs had strong bipartisan support once the financials were laid out in front of them. If you provide basic health care you prevent significant health problems and therefore people stay out of the hospital. It was a huge savings for the states that implemented it. I had a document on the savings somewhere but I cant find it in my email. Ill keep looking.

Im gonna leave my thoughts at that. Ill steer clear of posting more because policits gets people very upset.

 

[Bored Snorlax]

Let me know in 6-7 years if the clinic you work at sees Medicaid.

Fair. Not much I can do about it until I can operate independently and do things my own way.

My response was coming from my personal belief.

Its different when you have a spouse and kids to feed, as well as 3-5k a month in debt repayment.

I understand that there is an economic side and that pods should be properly compensated given all the time and sacrifices they put into their career. True, it may not be financially possible for some and that's understandable. However, people who are in a favorable position should offer assistance. For example, if the general public has a better perception and image of podiatry, patients would have more trust and confidence in the field and that would open more opportunities for podiatrists.

 

[Weirdy]

For example, if the general public has a better perception and image of podiatry, patients would have more trust and confidence in the field and that would open more opportunities for podiatrists.

Preaching to the choir again.

Many of us have done outreach stuff, held positions, etc etc to push for all of that.

Maybe we're just jaded as you are just beginning.

 

[DYK343]

Also, its pretty darn easy to bill a 99214 or even a 99215 for a DPM.

Most encounters should easily qualify for a 99214 unless they are there only for procedure.

In the past it was 99213s across the table with an occasional 99214.

Looks like they might be cutting it back 2.5%. But the reimbursements are up overall significantly in the last few years.

 

[HardRoadPaved]

Also, its pretty darn easy to bill a 99214 or even a 99215 for a DPM.

How so?

ordering an x-ray in your office and then reviewing it is excluded for points if you own the machine and bill 7xxxx code.

Terms to define: "prescription drug management" (haha like lamisil) , major vs minor surgery (like 10 vs 90 day global?)

 

[Boba Foot]

When I was a student and got sick I didn't go to the doctor or hospital because even with the school's insurance I couldn't pay the copay.

This is why it’s a crappy system. You pay a monthly premium for health insurance, and then when you actually need to use it, you don’t because you don’t want to pay more out of pocket. So essentially you’re paying monthly premiums to private insurance and they never actually have to cover any service for you. You’re 100% profit to them. They must love you. Hopefully they at least sent you a Christmas card.

 

[DYK343]

How so?

View attachment 364157

ordering an x-ray in your office and then reviewing it is excluded for points if you own the machine and bill 7xxxx code.

Terms to define: "prescription drug management" (haha like lamisil) , major vs minor surgery (like 10 vs 90 day global?)

1 new problem - Plantar fasciitis.
Review PCP referral note,
Read or order Xray (im not private so it counts) and interpret myself - "no, its not the bone spur causing your pain despite the radiology read of bone spurs".
Order NSAID (any prescription drug is drug management so ive been told - even a topical antifungal cream).
Discuss conservative care.
According to my billers thats a 99214.

 

[wakaflocka88]

1 new problem - Plantar fasciitis.
Review PCP referral note,
Read or order Xray (im not private so it counts) and interpret myself - "no, its not the bone spur causing your pain despite the radiology read of bone spurs".
Order NSAID (any prescription drug is drug management so ive been told - even a topical antifungal cream).
Discuss conservative care.
According to my billers thats a 99214.

I was told the same by my billers. Even a 11750/20550 etc can be a level 4 because there’s inherent risk with any procedure, even small. Now, patients may be angry when they receive a big bill for a simple PF visit since it was billed as a level 4 (happened to me a few times) but I don’t care. Realistically these patients suck up 20-30 mins trying to argue with them the spur is not the cause of the pain.

 

[Shiyuan]

Any rx med (non-otc) prescribed = automatically 99214.

 

[PatchAdamsFan]

@DYK343 @wakaflocka88 Absolutely right. The E/M codes have very simple rules either by medical decision making, or time. It has nothing to do with "plantar fasciitis/etc doesn't feel like a level 4 visit" that I'm sure many and myself have heard said in residency. Bill for what you did. Document well, and you'll pass any audit that us pods in particular are fearful of. Many of my specialist colleagues don't even bill level 3 visits. As I said previously, level 3, 4, and 5 E/M repeat visit RVU increase has gone up 34%, 28%, and 32.7% respectfully since 2020.

 

[HardRoadPaved]

It has nothing to do with "plantar fasciitis/etc doesn't feel like a level 4 visit"

Amen. As long as you have the justification in categories it is what it is. For those in PP, doing the x-ray and billing for it knocks you down. Also not having a PCP note to review.
However you wont get there in category 1 as most plantar fasciitis is "acute illness without systemic symptoms".... unless they are your repeat classic chronic plantar fasciosis patients.

Even a 11750/20550 etc can be a level 4 because there’s inherent risk with any procedure, even small.

So that's def up for debate. Of course all surgeries carry risk but the box says "identified risk factors" I reserve level 4 for those with a comorbidity like neuropathy, circulation etc.

My assumption is that minor = 10 day global stuff and major = 90 global stuff

 

[dtrack22]

1 new problem - Plantar fasciitis

It’s not as simple as 1 new problem though. It needs to be a new problem with an uncertain prognosis or an acute “complicated” injury. Many of the new problems we dx are still considered low complexity

Any rx med (non-otc) prescribed = automatically 99214.

Not true, you still need either the necessary problem or data points

 

[Shiyuan]

Not true, you still need either the necessary problem or data points

I usually include a discussion of labs, rx interactions, side effects, etc.... 🤷🏻‍♂️😬

 

[Feli]

OK bro, and your alternative is the party that wants to eliminate Medicare altogether.

Was not intended to be a political thing... went to the gym and came back and saw all of this. Lol, I don't even vote typically.

...For PP, the only color that matters is green... not red/blue.

With dems in control, there are usually MCR cuts, but when the economy's not good, it's consequently easier to find employees and negotiate rent and get deals on supplies or services, etc.
With repubs, it is more likely that MCR rates stay stable, but if there's boom time, it's usually harder to find and keep employees, value supplies and services, etc.
It is sorta six of one, half dozen of the other imo. That's all I was saying.

I am an independent voter. I refuse to vote solely on party lines. Thats for sheeple...

I have never seen the point to consuming time and energy on people who don't know your name. They are all in lobbyist pockets and out for themselves. They say one thing and do another (usually do nothing) once elected. Not a wise use of one's time to subscribe to it all... unless one legit enjoys the CNN/Fox info and the associated labetalol/atorvastatin they need from it?

 

[dtrack22]

I usually include a discussion of labs, rx interactions, side effects, etc....

Discussion of labs might be one data point, you need more for a level 4 visit (or sufficient problem points). Rx interactions is a part of the risk category for therapeutic drug management. You may or may not hit a moderate level of complexity. But Rx = level 4 isn’t automatically true just because of the prescription.

 

[Shiyuan]

Discussion of the many flavors of Kerasal = 99215 💩🦶🏻🕺

 

[DYK343]

I have never seen the point to consuming time and energy on people who don't know your name. They are all in lobbyist pockets and out for themselves. They say one thing and do another (usually do nothing) once elected. Not a wise use of one's time to subscribe to it all... unless one legit enjoys the CNN/Fox info and the associated labetalol/atorvastatin they need from it?

Politicians main goal IMO is to pin americans against americans. The more divided we are the more secure their job is.

 

[Scrantonicity]

Foodstamps exist.

Access to food, shelter, and medicine should be at the foundation of a 1st world country.

Yeah...but the point of their existence was really to help people get on their feet and get OFF of them. I think the foundation of a 1st world country should be free people working and EARNING access to food, shelter, and medicine...to have that satisfaction and happiness that comes with that self-reliance. I can't imagine feeling satisfaction of having to depend on others your ENTIRE LIFE...Unfortunately, the system is designed to let people do just that. Also, as you said--it's comically easy to abuse it. And we want to expand that? Guess that's the big debate, though...oh well.

 

[heybrother]

2023 fee schedule is up- damn fast.

E&M codes didn't move much but 28232 dropped $15.