- Joined
- Oct 17, 2011
- Messages
- 3,463
- Reaction score
- 8,032
There was a prior discussion on this forum concerning insurance negotiations. I would love to know how things are going for other people. These are my recent experiences.
1. Large national insurance company. Commercial insurance contracts paying sub-Medicare in office for everything and ~107% of Medicare for surgery in ASC, but 1/4th of starting reimbursement for 3rd procedure in all circumstances so the more you do the less you get. Very difficult to ultimately get in touch with a person. Major bummer - a huge local employer switched to this insurance from BCBS so cases that were previously a positive multiplier over Medicare and supported the office are now essentially negative/worthless. Got in contact with reimbursement rep. Was told most people on plan are in "self insured plans" so they won't negotiate with me to save money for these employers. Yeah, its the local employer above. I asked the employer for help. They said its out of their hands. Asked insurance company for contract but haven't received it. Am going to test the waters telling people I will not operate on them because of their insurance and see what happens. Had a bunch of people in a row who potentially need involved surgery ie. calcaneal osteotomies, TN fusions etc. Interestingly this insurance company maintains a tiny network associated with one of these plans and has no foot and ankle orthopedists. Literally got a patient the other day that ortho told they couldn't see anymore after a medial mal / talar dome repair. Person is still hurting.
2. Large government insurance plan that is supposed to be full Medicare, but is run by private contractors who try to cut rates. In a prior year, a "MAC" type company within it cut my rates and I could never figure out who to call to fight it. Ultimately got the rates restored without much difficulty after finally speaking to a rep. This time around I spent more than a year running in circles trying to figure out who to speak to. My rates had been cut by 20-25% without any interaction. They simply sent me a letter a year ago saying "you don't need to do anything... and then the last page cut rates". I finally got someone on the phone this week and they asked me if I'd take 95% of Medicare. They wanted to know what level of discount I was willing to take. "None". I told them I'd already stopped seeing their new patients and I wouldn't take a cut. I provided a long list of reasons why they needed to pay me 100% of Medicare including that none of the private orthos in my town would take the insurance. Ultimately they appear to have caved and agreed to 0% discount. They said they had to speak to their boss before offering me the rate I wanted. Still waiting on the addendum to arrive. In short - in the span of like maybe 1.5 years I've had to fight 2 separate times to prevent a problematic goverment payor from cutting rates with a wave of their finger.
3. Some small plan wrote to me claiming they had multiple patients scheduled to see me and would within reason pay me whatever I asked for. However, the contract they sent me had 120% already written in. I asked for more and they ghosted me. They literally had included all sorts of paperwork essentially saying they wanted to co-exist with physician offices and all sorts of rainbows and unicorns with charts showing increased physician reimbursement. I'm mostly of the opinion plans like this exist so TPAs can undercut BCBS/Cigna and sell insurance to small self insured companies.
4. Small(? - honestly not sure) plan through a CIN network I'm with. Sent me a contract requesting to pay me 120% of Medicare. I wrote back and asked that CPT codes be paid 180% of Medicare. The person wrote back offering me 150% of all codes ie. E&M / CPT / imaging - technically splitting the difference between their offer and mine. I wrote back and told them it would be signed tomorrow if it was 160%. They had to get authorization and ultimately it got signed for 160% of everything. I will fully concede that 160% is not actually hot reimbursement for actual surgery, but there are far more 99204+xrays coming in to discuss surgery than to actually commit to surgery. My IPA had provided me a diversity of contracts that were interesting - a straight 165%, a 135/150/175%, and a 135/150/185%. For something negotiated without them this felt in line with prior rates we'd been able to get through the group.
5. Large company in state. Horrible interactions with them in the past ie. asked for help with rates and got some E&M increases but massive CPT cuts. Contacted local rep asking for increase in rates again as it had been several years. Was sent to some website where I could request contract modifications. Sent off a polite request. Never heard back. Realized I never got a confirmation email so I wasn't even sure how long I'd already waited other than using the email from the first rep. Ultimately contacted them again. Finally heard back. They offered trivial increases to E&M, radiology - maybe 5%, if I recall a 15% increase to CPT, and a cut to DME. I wrote back asking for more and reversal of the DME cut. Ultimately they increased the CPT rate I think another 5% and undid the DME cut. However, I have since been contacted by a local rep who heard we weren't satisfied and I'm going to keep bugging them for more. If an aggrieved email gets you another $5 a patient/encounter then you should send them. Nothing in this contract exceeds 130% of Medicare but I think we increased one component of the contract by 20% - albeit underlying Medicare rates keep falling so we're in many ways just treading water.
6. Some new Medicare Advantage plan contacted us the other day asking if we were interested. I'm really not, but I'll write to them and ask for 120% just to see what happens. Costs nothing. They can ghost me, but I don't care. Make yourself available to Medicare Advantage plans undercuts real Medicare, sets you up for denials from fraud factory companies that shouldn't exist and creates the appearance these plans have real networks.
7. My partner wanted me to ask a plan we'd left what they'd pay if we rejoined. The rates are still crap ie. 90% of Medicare (which could maybe be negotiated up 5%), but much worse than that - the contract they offered us is now ENORMOUS. It used to be short and straight forward. Its got all sorts of "you shalls" that weren't in it previously. I would tell people to definitely read the hell out of contracts from large national Medicare Advantage plans. For example - this new contract wants the practice to have new malpractice group coverages that we don't have - we just have individual malpractice. It also wants us to create all sorts of quality committees within the practice - there are 2 of us. Last of all - we can't stop accepting new patients from them without contacting them and working to resolve our differences. What's the first thing you do when a plan starts defrauding you or not paying you - limit your liability by not accepting new patients. Not on this contract. They are now sending me emails every week to remind me to sign the contract.
-I have still never had an interaction with an insurance company where asking for help on a particular CPT code works. Everyone wants to do a percentage of Medicare.
-While I managed to resolve one above, E&M continues to be underpaid compared to CPT. My suspicion is this is because plans with copays usually have to cover the rest of the visit after the copay so a high E&M reimbursement rate transfers more financial liability to the insurance company.
-Tying reimbursement to Medicare is convenient for insurance companies but problematic for us because underlying Medicare rates continue to decline.
-Its not just a case of negotiating good rates with plans. You have to read the contract. You have to know the contact points for reps associated with your plans.
-People will tell you that you should ask for a rate increase every year, but many plans make it difficult to figure out who to ask.
-Large insurance companies continue to simply unilaterally decrease provider rates with contract addendums in which you have no feedback.
-Some of the above felt relatively decent. I'd had periods in the past with my office where I thought "I've stopped the bleeding", but my inability to resolve issues with a local common payor remains problematic to me.
-Always be planning your next email explaining why you need more. Their email offering you a bit more should always trigger a higher counter offer.
-My weird battle on asking for more though is that - sometimes I think the things we value are things they don't value. For example - you think - I'll make a case that I'm an amazing surgeon, that I set woundcare patients free from expensive hospital facility HBO tanks. I wonder do the insurance reps just hear "expensive facility surgery".
Podiatry for me at least remains a volume business.
1. Large national insurance company. Commercial insurance contracts paying sub-Medicare in office for everything and ~107% of Medicare for surgery in ASC, but 1/4th of starting reimbursement for 3rd procedure in all circumstances so the more you do the less you get. Very difficult to ultimately get in touch with a person. Major bummer - a huge local employer switched to this insurance from BCBS so cases that were previously a positive multiplier over Medicare and supported the office are now essentially negative/worthless. Got in contact with reimbursement rep. Was told most people on plan are in "self insured plans" so they won't negotiate with me to save money for these employers. Yeah, its the local employer above. I asked the employer for help. They said its out of their hands. Asked insurance company for contract but haven't received it. Am going to test the waters telling people I will not operate on them because of their insurance and see what happens. Had a bunch of people in a row who potentially need involved surgery ie. calcaneal osteotomies, TN fusions etc. Interestingly this insurance company maintains a tiny network associated with one of these plans and has no foot and ankle orthopedists. Literally got a patient the other day that ortho told they couldn't see anymore after a medial mal / talar dome repair. Person is still hurting.
2. Large government insurance plan that is supposed to be full Medicare, but is run by private contractors who try to cut rates. In a prior year, a "MAC" type company within it cut my rates and I could never figure out who to call to fight it. Ultimately got the rates restored without much difficulty after finally speaking to a rep. This time around I spent more than a year running in circles trying to figure out who to speak to. My rates had been cut by 20-25% without any interaction. They simply sent me a letter a year ago saying "you don't need to do anything... and then the last page cut rates". I finally got someone on the phone this week and they asked me if I'd take 95% of Medicare. They wanted to know what level of discount I was willing to take. "None". I told them I'd already stopped seeing their new patients and I wouldn't take a cut. I provided a long list of reasons why they needed to pay me 100% of Medicare including that none of the private orthos in my town would take the insurance. Ultimately they appear to have caved and agreed to 0% discount. They said they had to speak to their boss before offering me the rate I wanted. Still waiting on the addendum to arrive. In short - in the span of like maybe 1.5 years I've had to fight 2 separate times to prevent a problematic goverment payor from cutting rates with a wave of their finger.
3. Some small plan wrote to me claiming they had multiple patients scheduled to see me and would within reason pay me whatever I asked for. However, the contract they sent me had 120% already written in. I asked for more and they ghosted me. They literally had included all sorts of paperwork essentially saying they wanted to co-exist with physician offices and all sorts of rainbows and unicorns with charts showing increased physician reimbursement. I'm mostly of the opinion plans like this exist so TPAs can undercut BCBS/Cigna and sell insurance to small self insured companies.
4. Small(? - honestly not sure) plan through a CIN network I'm with. Sent me a contract requesting to pay me 120% of Medicare. I wrote back and asked that CPT codes be paid 180% of Medicare. The person wrote back offering me 150% of all codes ie. E&M / CPT / imaging - technically splitting the difference between their offer and mine. I wrote back and told them it would be signed tomorrow if it was 160%. They had to get authorization and ultimately it got signed for 160% of everything. I will fully concede that 160% is not actually hot reimbursement for actual surgery, but there are far more 99204+xrays coming in to discuss surgery than to actually commit to surgery. My IPA had provided me a diversity of contracts that were interesting - a straight 165%, a 135/150/175%, and a 135/150/185%. For something negotiated without them this felt in line with prior rates we'd been able to get through the group.
5. Large company in state. Horrible interactions with them in the past ie. asked for help with rates and got some E&M increases but massive CPT cuts. Contacted local rep asking for increase in rates again as it had been several years. Was sent to some website where I could request contract modifications. Sent off a polite request. Never heard back. Realized I never got a confirmation email so I wasn't even sure how long I'd already waited other than using the email from the first rep. Ultimately contacted them again. Finally heard back. They offered trivial increases to E&M, radiology - maybe 5%, if I recall a 15% increase to CPT, and a cut to DME. I wrote back asking for more and reversal of the DME cut. Ultimately they increased the CPT rate I think another 5% and undid the DME cut. However, I have since been contacted by a local rep who heard we weren't satisfied and I'm going to keep bugging them for more. If an aggrieved email gets you another $5 a patient/encounter then you should send them. Nothing in this contract exceeds 130% of Medicare but I think we increased one component of the contract by 20% - albeit underlying Medicare rates keep falling so we're in many ways just treading water.
6. Some new Medicare Advantage plan contacted us the other day asking if we were interested. I'm really not, but I'll write to them and ask for 120% just to see what happens. Costs nothing. They can ghost me, but I don't care. Make yourself available to Medicare Advantage plans undercuts real Medicare, sets you up for denials from fraud factory companies that shouldn't exist and creates the appearance these plans have real networks.
7. My partner wanted me to ask a plan we'd left what they'd pay if we rejoined. The rates are still crap ie. 90% of Medicare (which could maybe be negotiated up 5%), but much worse than that - the contract they offered us is now ENORMOUS. It used to be short and straight forward. Its got all sorts of "you shalls" that weren't in it previously. I would tell people to definitely read the hell out of contracts from large national Medicare Advantage plans. For example - this new contract wants the practice to have new malpractice group coverages that we don't have - we just have individual malpractice. It also wants us to create all sorts of quality committees within the practice - there are 2 of us. Last of all - we can't stop accepting new patients from them without contacting them and working to resolve our differences. What's the first thing you do when a plan starts defrauding you or not paying you - limit your liability by not accepting new patients. Not on this contract. They are now sending me emails every week to remind me to sign the contract.
-I have still never had an interaction with an insurance company where asking for help on a particular CPT code works. Everyone wants to do a percentage of Medicare.
-While I managed to resolve one above, E&M continues to be underpaid compared to CPT. My suspicion is this is because plans with copays usually have to cover the rest of the visit after the copay so a high E&M reimbursement rate transfers more financial liability to the insurance company.
-Tying reimbursement to Medicare is convenient for insurance companies but problematic for us because underlying Medicare rates continue to decline.
-Its not just a case of negotiating good rates with plans. You have to read the contract. You have to know the contact points for reps associated with your plans.
-People will tell you that you should ask for a rate increase every year, but many plans make it difficult to figure out who to ask.
-Large insurance companies continue to simply unilaterally decrease provider rates with contract addendums in which you have no feedback.
-Some of the above felt relatively decent. I'd had periods in the past with my office where I thought "I've stopped the bleeding", but my inability to resolve issues with a local common payor remains problematic to me.
-Always be planning your next email explaining why you need more. Their email offering you a bit more should always trigger a higher counter offer.
-My weird battle on asking for more though is that - sometimes I think the things we value are things they don't value. For example - you think - I'll make a case that I'm an amazing surgeon, that I set woundcare patients free from expensive hospital facility HBO tanks. I wonder do the insurance reps just hear "expensive facility surgery".
Podiatry for me at least remains a volume business.
Last edited:
