Are 'check fees' normal from insurance payments?

[p100]

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Extorting 5% for Electronic Payments to Providers - PNHP

Share on FacebookShare on Twitter Summary: When CMS tried to enforce a 15-year-old rule that insurers cannot charge providers for electronic…read more

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A powerful lobbyist convinced a federal agency that doctors can be forced to pay fees on money that health insurers owe them. Big companies rake in profits while doctors are saddled with yet another cost in a burdensome health care system.

It was a multibillion-dollar strike, so stealthy and precise that the only visible sign was a notice that suddenly vanished from a government website.

In August 2017, a federal agency with sweeping powers over the health care industry posted a notice informing insurance companies that they weren’t allowed to charge physicians a fee when the companies paid the doctors for their work. Six months later, that statement disappeared without explanation.

I don't remember where I originally saw this, maybe some one posted it here.

Anyways, that is not the point. I have been taking some insurances by check to avoid this fee. On my latest Humana check it deducted $5 for a "check fee". I will be checking future checks to see if this recurs.

Does anyone know about this "check fee"? Is it an annual or monthly fee? It's going to suck if expenses increase another 3% because there is no other way to get paid.

 

[heybrother]

I went back and looked through a lot of claims, spoke to my office manager, etc. I can't find this happening to my practice. I've only seen 1 patient with Humana as their primary this whole year - no penalty. The impression I'm under is that our major payors go entirely electronically. Its our Medicare secondaries and small payors that normally do those electronic credit cards or checks.

Without trying to sound triggered - these little constant cuts are the things that will drive you crazy so I feel for you that this is happening. No doubt about it - CMS is in a state of regulatory capture.

The WSJ's editorial department is a land of trash shills, but their reporting side is doing God's work showing how Medicare Advantage plans are destroying medicine.

 

[Feli]

I have seen it a few times.

The much more problematic thing is all of the 'virtual card' payments... wastes your staff's time entering the 'card' info in... and charges you 2% or 3% or whatever your card processor service charges. This happens with various payers, work comp, etc.

PS, drop Hew Mannah.

.... I've only seen 1 patient with Humana as their primary this whole year ...

This is the way. Now try to reduce that number by 100% for next cycle.

 

[heybrother]

I have seen it a few times.

The much more problematic thing is all of the 'virtual card' payments... wastes your staff's time entering the 'card' info in... and charges you 2% or 3% or whatever your card processor service charges. This happens with various payers, work comp, etc.

PS, drop Hew Mannah.


This is the way. Now try to reduce that number by 100% for next cycle.

When I left Humana I had

1. A horrible low paying contract. Lower than anyone I've ever met or spoken to.
2. Tons of unpaid 11720's that they claimed were "bundled" with 11056
3. And a bunch of patient's with wounds where you'd do bone work to resolve a location and then they'd never pay for a 11042 anywhere else on the patient even though the person had plural ulcers on both feet. Here's $200 for bonework and everything else is free for the next 90 days with 8 debridements on the other foot stacking up for free and what not.

Humana was the main "retirement" Medicare Advantage plan for my area when I was dropping them, but United took it over right before it happened. And now I'm not in network with them either 🙂

I've had a plural number of patients tell me they switched from Medicare to Humana and they were back with Medicare as fast as their fingers could dial. They'd go to the cardiologist and find out that things that used to be paid for and covered weren't anymore.

The front desk essentially turns them away on the phone. That said - since we left, I no longer care if someone shows up begging to be seen and has Humana. The guy above paid a $65 copay and Humana paid the rest up to the Medicare fee schedule. It was a 99203/73630x2 visit to the tune of like $170 for 10 minutes of my time. OON all the way. I once had a patient I had seen years before go to the emergency room with a puncture wound and literally be told to just drive to my office and beg to be seen. My front desk receptionist was like - he has Humana. I was like - I think I'm going to hell if I don't see this guy. No issues. Haven't had a denial since we left though I'm not looking for chronic wounds or nails.

 

[Homo sapien]

When I left Humana I had

1. A horrible low paying contract. Lower than anyone I've ever met or spoken to.
2. Tons of unpaid 11720's that they claimed were "bundled" with 11056
3. And a bunch of patient's with wounds where you'd do bone work to resolve a location and then they'd never pay for a 11042 anywhere else on the patient even though the person had plural ulcers on both feet. Here's $200 for bonework and everything else is free for the next 90 days with 8 debridements on the other foot stacking up for free and what not.

Humana was the main "retirement" Medicare Advantage plan for my area when I was dropping them, but United took it over right before it happened. And now I'm not in network with them either 🙂

I've had a plural number of patients tell me they switched from Medicare to Humana and they were back with Medicare as fast as their fingers could dial. They'd go to the cardiologist and find out that things that used to be paid for and covered weren't anymore.

The front desk essentially turns them away on the phone. That said - since we left, I no longer care if someone shows up begging to be seen and has Humana. The guy above paid a $65 copay and Humana paid the rest up to the Medicare fee schedule. It was a 99203/73630x2 visit to the tune of like $170 for 10 minutes of my time. OON all the way. I once had a patient I had seen years before go to the emergency room with a puncture wound and literally be told to just drive to my office and beg to be seen. My front desk receptionist was like - he has Humana. I was like - I think I'm going to hell if I don't see this guy. No issues. Haven't had a denial since we left though I'm not looking for chronic wounds or nails.

Are you saying you get better payment seeing humana as out of network coverage

 

[heybrother]

Are you saying you get better payment seeing humana as out of network coverage

Yes.

I had a 65% of Medicare contract when I was in with Humana.

1. If you have a sub-Medicare contract in network.
2. And the patient's have a "PPO" plan
3. And the patient's are willing to pay the OON copay - which is $65 in my area

Then you are likely to be reimbursed at about 100% of your Medicare locality fee schedule OON.

If a patient has a HMO Medicare Advantage plan and you are OON - you will not be paid and the patient will get handed the entire bill.

It is possible that some people won't even owe more money if they are on some sort of retirement type MA plan. For example, I am OON with United Medicare Advantage also, but patients who have TRS (teacher's reitrement) or HealthSelect (hospital retirement plans) essentially reimburse the same in and out of network and I'm reimbursed at the full Medicare fee schedule has opposed to taking a contractual cut.

That said. Humana will also likely still fraudently attempt to deny nails.

There's actually CMS guidance documents online that spell this out. I'll post later weekend.

 

[heybrother]

Are you saying you get better payment seeing humana as out of network coverage

Briefly one more thing -

1) If all the Medicare Advantage plans in your area are mostly PPO
2) And your staff are smart enough to recognize the words HMO on a card
3) And your local MA Advantage plans are super aggressive in offering bad contracts - wanting you to take 65%, 75%, 85% etc
4) And you are ok with a patient paying a higher copay. ie. normally $40->$65

You should drop them. The simple truth is - we deserve more than what Medicare pays and we certaintly don't deserve to be ripped off by for profit billionaire garbage MA companies.

I read a great article online where a consultant is telling hospitals not to even accept Medicare Advantage plans unless they pay 115%.

Last Friday - I spent an hour on the phone with Aetna MA trying to get an MRI approved for a wound that probes to bone. They denied and said we needed a peer to peer. I never actually got on the phone with a "peer" but after an hour on the phone they agreed to review our notes. Why was the MRI denied to begin with. Because of Fraud by Aetna Medicare Advantage.

 

[HardRoadPaved]

Why was the MRI denied to begin with.

The denial grab bag clearly.....

 

[heybrother]

The first link below accurately describes my experience. The second link though is the actual CMS document on this topic.

Out-of-network payments in Medicare Advantage | The Incidental Economist

The complexity of Medicare Advantage (MA) physician networks has been well-documented, but the payment regulations that underlie these plans remain opaque, even to experts. If an MA plan enrollee sees an out-of-network doctor, how much should she expect to pay?

theincidentaleconomist.com

https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/OONPayments.pdf

 

[mandrew]

Never heard of a “check fee” from a payor. Virtual card fee, yes.

 

[p100]

Humana again charged me a $5 check fee. This check was $83 so that's a 6% fee. Oh well, at least they are only a small % of patients.

 

[mandrew]

Humana again charged me a $5 check fee. This check was $83 so that's a 6% fee. Oh well, at least they are only a small % of patients.

Interesting, is Humana the only one that has ever done this?

 

[p100]

Interesting, is Humana the only one that has ever done this?

As far as I know, yes.

 

[p100]

Update. Humana is charging a $5 check fee on every single check, not just weekly or monthly. Even $20 checks get cut to $15.

 

[heybrother]

Update. Humana is charging a $5 check fee on every single check, not just weekly or monthly. Even $20 checks get cut to $15.

A few thoughts for you -

-I have never dropped an insurance that called back during or after and said "please don't go" or "we got the termination, let's work this out". There is no email. There is no phonecall. There is just the ultimate termination date. We are nothing to them. There will always be another doctor who is willing to bend over.
-I have never had a commercial plan, MA plan show a willingness to negotiate in any substantial fashion.
-The internet says you should make a pitch to them about the value of your services, how unique you are, how great you are, how you will save them money on other costs by the value of your services and surgeries. Doesn't work. You are dealing with low-mid-level bureacratic slugs. They would not understand how value is offered.
-Costs are saved by directly reducing your reimbursement.
-The internet also says that you should ask them for help with your worst fee schedule codes or alternatively common codes. Doesn't work. This one massively blew up in my face, but in general insurance companies always work off either (a) some sort of generic fee schedule table that the company designed or (b) a CMS fee schedule table with a multiplier. They will happily create generic fee schedule tables with bad carve outs to be used against you, but I have never seen a company change individual values in a table to benefit me. Their preference is usually using CMS and going from there. Changing values individually for you probably has the ability to create gamesmanship on the doctors part.
-MA plans are VERY used to doctors claiming they will leave and then not leaving. Its the only leverage doctors have and after the company says no most just continue to wallow.

I thought that I could fix things. I thought that I could change things. You cannot. All you can do is leave.

 

[Feli]

Today, on True Stories of Podiatry:

" My biller: Hi [H bro], I just reviewed the contract. Will you please send me H's fee schedule so I can see what our reimbursement will be? Thank you!

Starts-with-an-H 'Contracting Professional' Rep: The 2024 state schedules are not available yet. I have been checking but no luck. Here is third quarter 2023, hopefully this will help.

MB: Thank you! Essentially this fee schedule is a little over 100% of current medicare. Any chance we can get a bump to 115% as he's the most experienced and only surgery board-certified podiatry provider in his county?

HCPR: The fee schedule I shared is a default. Our current rates listed on the agreement for podiatry would land at 95% of that fee schedule. Senior leadership will not approve rates above standard.

MB: That's very unfortunate. H is not even offering 100% of medicare rates for the medicare advantage plans?

HCPR: Rates are specific for each market by provider specialty and in state H does not offer 100% on new podiatrist agreements. Do you wish to proceed at these rates, or shall I recall the offer?

MB: I will talk to Dr. [Feli] and get back to you soon. Thanks. "

...H then goes on to not even pay most things, send much to pt responsibility, reject tons (esp surgery and procedures), make PAs hard, slow pays, all kinds of issues.

A few thoughts for you ...

...We are nothing to them. There will always be another doctor who is willing to bend over. ...
... I thought that I could change things. You cannot. All you can do is leave.

Yes... 1000%
The "another doctor who is willing" goes triple in podiatry.
This should be taught in pod school - and/or residency.
Or "fellowship" 🤣

 

[p100]

A few thoughts for you -

.....

I thought that I could fix things. I thought that I could change things. You cannot. All you can do is leave.

Yes. I'm already planning my escape or long term plan away from podiatry.

On a positive note I must say working for myself has been excellent overall even with all the annoying things like check fees and random insurance denials.

 

[heybrother]

Yes. I'm already planning my escape or long term plan away from podiatry.

On a positive note I must say working for myself has been excellent overall even with all the annoying things like check fees and random insurance denials.

I've said this elsewhere, but I'm using AI lately to do my notes and one of the consequences of this is that all my visits are timed ie. I used to think I was in the room forever, but now I know if I was or wasn't. I will tell you that when things are flowing and people are saying yes - the revenue that can be generated per hour is substantial. We all have our ups and downs. The other day I had an afternoon where 4 people in a row with plantar fasciitis all said no to an injection. But there are other times where I think - we need more, more, more encounters like these.

Last thing on BCBS - I don't know what your fee schedules are, but commercial 11055/56/57 are pretty handsomely paid in my office. I know we always want more, but call a spade a spade. Maybe you aren't experiencing that, but my office used to inappropriately bill commercial visits for Q care as 99213. We were leaving a lot of money on the table.

 

[mandrew]

I've said this elsewhere, but I'm using AI lately to do my notes and one of the consequences of this is that all my visits are timed ie. I used to think I was in the room forever, but now I know if I was or wasn't. I will tell you that when things are flowing and people are saying yes - the revenue that can be generated per hour is substantial. We all have our ups and downs. The other day I had an afternoon where 4 people in a row with plantar fasciitis all said no to an injection. But there are other times where I think - we need more, more, more encounters like these.

Last thing on BCBS - I don't know what your fee schedules are, but commercial 11055/56/57 are pretty handsomely paid in my office. I know we always want more, but call a spade a spade. Maybe you aren't experiencing that, but my office used to inappropriately bill commercial visits for Q care as 99213. We were leaving a lot of money on the table.

Q care?

 

[Adam Smasher]

Q care?

Routine callus care for patients with PAD modifiers--Q7/Q8/Q9

One of the stupidest things about this profession full of stupid things is how well callus care is reimbursed compared to things we do that actually require half a brain and serve a meaningful benefit to a patient. In a different thread, we were joking around about skin biopsies and how aggressive some DPMs will be with their indications for them. In my opinion it's a moot point. A 1105x reimburses about 60-80% as well as a 1142x but in 20% of the time with none of the liability, none of the patient discomfort, and none of the follow-up.

It's part of the broader podiatric trend of topsy-turvy reimbursement patterns where it makes better sense to mitigate and baby people's problems than to actually solve them. I've had cases that reimbursed less than the CAM boot I give the patient after surgery. Would you surgically offload the patient's ulcer to get them healed for $ or periodically debride them for a year or more to enjoy a cashflow? This is why I have patients with ingrowns coming to me whose other docs just trimmed out the corner every few months rather than doing the matrixectomy day 1. This is why I have patients who are "prescribed" orthotics to cure their bunions. There are too many other examples of how we are financially disincentivized to help our patients.

 

[MicroPod]

Worked with an attending in residency who never ever talked to patients about stretching for plantar fasciitis. He would however do ultrasound, offer steroid injection, try to push custom orthotics, do taping, discuss expensive in house supplements and would offer in house robotic laser all in the same visit.

 

[Feli]

Worked with an attending in residency who never ever talked to patients about stretching for plantar fasciitis. He would however do ultrasound, offer steroid injection, try to push custom orthotics, do taping, discuss expensive in house supplements and would offer in house robotic laser all in the same visit.

That's the real world. ^^

E/Ms won't do it.... need to offer other CPTs and more stuff. Pod school's not cheap.
Stretch/massage should be mentioned and encouraged for PF, but how many people do we think actually do the calf stretches and arch massage we advise regularly? Not many (even if they go to Rx PT and the PT instructs them).

That said, there is a balance.
It doesn't make one a salesman to "maximize" visits (and bill up a storm)...
also doesn't make one an angelic pure patient advocate to 'go slow' (and do next to nothing for the pt).

My first PP owner boss was a very mediocre pod (academically/surgically), but a very good pod overall, esp in terms of owner/revenue/efficiency... pretty good with ppl and super savvy with biz aspect. I learned a ton. He had collections of $1M/yr at least a few time (and that was over a decade ago). He told me early and often that people are at the office since they've already tried OTC stuff like NSAID or compoundW or gel insoles or whatever is in the foot care section at the pharmacy that pertains to their problem. They have often even tried night splint or Voltaren or arch support at running store or abx from PCP or whatever. Many people also had a midlevel or their FP doc try a tx or two like inject or lesion destruction or even DME or ingrown procedure. What we do is not very hard (the non-op dx/tx part).

Basically, patients with a job and decent insurance (which is what you should be mainly seeing in PP) don't like going to the doctor and are afraid of the cost and time off work. They have tried what PCP or Urgent Care told them, and they tried what they can find at Walgreens or YouTube or family or neighbour said might work... and it didn't work. Do not underestimate that or fail to grasp it. It's important. If Neosporin and cotton wisps fixed ingrowns or if the OTC ankle brace and a Tylenol took the pain away, they would have cancelled the appointment.

Ergo, it's not wrong to flyyy through those OTC/basic options and skip to offering injects or more advanced stuff early and often. This is the country that invented fast food. We can't even sit through shows or YTube... we shorten it to Tok or Snap. People (almost always) want fast answers, quick fixes... and once you get good, you also need to get them better fast and free up those visit spots for other new patients anyways. There is a balance between pushing treatment and doing a whole lotta nothing.

PS, tapings and Jones wraps only a good use of time if you know your payers pay them, if MA does them, or if pt really needs it.

 

[heybrother]

A lot of those options are just cashification. Talking about them just wastes your time and wastes the patients time. Medicare does not pay for custom orthotics. Obamacare plans do not pay for custom orthotics. You are essentially fishing for customs in a shrinking pond and burning daylight unless you have checked everyone's insurance ahead of time. A lot of patients know chiropractors offer laser and that it doesn't work. There was nothing sadder to me 4th year than listening to a podiatrist push custom after custom on patients over and over again and sell none. Just move on.

Office visit + 20550 when appropriate in one of the most straight forward visits out there. The patient gets better. The office makes some money. The codes can be submitted to insurance. You obviously have to bill appropriately, but 99213 or 20550 in isolation will not keep the lights on. There's unfortunately too much ridiculousness in fee schedules ie. bad commercial visits devalue both, Medicare somewhat adequately values E&M but devalues CPT, and even good commercial plans sometimes adequately value CPT but devalue E&M ie. all my major payors pay less than Medicare for E&M.

Insurance catches on to a lot of things and often devalues them. Consider ultrasound - in my area a lot of the commercial payors that pay a positive multiplier for CPT still pay ultrasound less than Medicare. I think they know in a lot of cases podiatrists are spending about 1 minute pointing the probe at an Achilles or at the plantar fascia. There is literally a commercial plan that pays near $200 for a "complete" and pays $30 for limited. That's about the value of 3 view x-ray.