Are the 500K+ days in derm over...

[cableguy555]

derm seems to be getting a lot of competition? PAs and NPs now can do a lot of things they do? I was just in family medicine and one of our attendings and her friend do almost everything a dermatologist does including excisions EXCEPT Moh's surgery. what do people think abbout that?

But couldn’t that be said about any other non-surgical specialty? Even zocdoc allows PAs and NPs to advertise their services. That being said, a patient who goes to a PA is one who probably doesn’t have the best insurance or is looking to save money.

I’d rather treat a patient who is willing to pay the “specialist” copay and be a regular than one who nags about pricing and discounts. I’m addition, I doubt a PA could afford some the cosmetic derm equipment out there. My attending for my cosmetics rotation just bought a new laser for cellulite treatments and the machine itself costs $120k; that’s more than what most PAs make in an year.

In addition most family medicine physicians offering derm services have the worst kind of patients: entitled and cheap. If you are broke wannabe Instagram model wanting lip fillers, you’d probably go to a family physician offering it for $200 rather than the derm who charges twice as much. But does the derm actually want this person as a patient? Probably not!—because of unrealistic expectations and the hassle of negotiation.

In a simple supply-demand curve, if derms charge higher prices, they get less patients. In any other market, this would be disastrous but derms love it!! Why? Because they get fewer, but excellent, patients and the same amount of income when compared to seeing more but less quality patients.

I may be wrong but I don’t think Medicare reimburses non-derms for many derm procedures under its quality of service guidelines. In addition, Medicare only reimburses 75% of the its fee schedule to physicians assistants excluding the overhead bonuses. There really isn’t much incentive except on the cosmetics side for primary care physicians to be doing derm. Most insurance providers have strict coding procedures for non-derms doing derm procedures. For example, Aetna doesn’t reimburse for excisions performed by primary care doctors; it has to be billed as a general visit, at least in my state.

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[Dr. Bruce Banner]

But couldn’t that be said about any other non-surgical specialty? Even zocdoc allows PAs and NPs to advertise their services. That being said, a patient who goes to a PA is one who probably doesn’t have the best insurance or is looking to save money.

I’d rather treat a patient who is willing to pay the “specialist” copay and be a regular than one who nags about pricing and discounts. I’m addition, I doubt a PA could afford some the cosmetic derm equipment out there. My attending for my cosmetics rotation just bought a new laser for cellulite treatments and the machine itself costs $120k; that’s more than what most PAs make in an year.

In addition most family medicine physicians offering derm services have the worst kind of patients: entitled and cheap. If you are broke wannabe Instagram model wanting lip fillers, you’d probably go to a family physician offering it for $200 rather than the derm who charges twice as much. But does the derm actually want this person as a patient? Probably not!—because of unrealistic expectations and the hassle of negotiation.

In a simple supply-demand curve, if derms charge higher prices, they get less patients. In any other market, this would be disastrous but derms love it!! Why? Because they get fewer, but excellent, patients and the same amount of income when compared to seeing more but less quality patients.

I may be wrong but I don’t think Medicare reimburses non-derms for many derm procedures under its quality of service guidelines. In addition, Medicare only reimburses 75% of the its fee schedule to physicians assistants excluding the overhead bonuses. There really isn’t much incentive except on the cosmetics side for primary care physicians to be doing derm. Most insurance providers have strict coding procedures for non-derms doing derm procedures. For example, Aetna doesn’t reimburse for excisions performed by primary care doctors; it has to be billed as a general visit, at least in my state.

great ppoints!

 

[ERDOC555]

I may be wrong but I don’t think Medicare reimburses non-derms for many derm procedures under its quality of service guidelines. In addition, Medicare only reimburses 75% of the its fee schedule to physicians assistants excluding the overhead bonuses. There really isn’t much incentive except on the cosmetics side for primary care physicians to be doing derm. Most insurance providers have strict coding procedures for non-derms doing derm procedures. For example, Aetna doesn’t reimburse for excisions performed by primary care doctors; it has to be billed as a general visit, at least in my state.

Hmm... I've heard different things in this regard. Could you expound on this or provide links to where you saw this? I'm curious to know more.

I was under the impression that any doc can bill anything and get the full reimbursement amount. ie. FM excision = Derm excision = same reimbursement. Also I thought PA/NP with MD oversight can bill 100%?

 

[cableguy555]

Hmm... I've heard different things in this regard. Could you expound on this or provide links to where you saw this? I'm curious to know more.

I was under the impression that any doc can bill anything and get the full reimbursement amount. ie. FM excision = Derm excision = same reimbursement. Also I thought PA/NP with MD oversight can bill 100%?

I didn’t want to share my hospital’s reimbursement seminar slides due to privacy reasons but check out the link below. PA’s without supervision can only get 85% back. And the overhead bonus is usually another 10-12%.

https://www.clinicaladvisor.com/the...es-85-reimbursement-rule-fair/article/227380/

In one of our outpatient clinic rotations, we had an IM with us, it was his elective month. He was doing a light based treatment while I did the excision. We billed it under his name because his part took 40 min while mine was around 5 minutes. Patient came back a week later complaining about the treatment not being covered. The suits told us that a few insurances changed their policies to avoid paying the same reimbursements to non-specialists.

 

[asmallchild]

Hmm... I've heard different things in this regard. Could you expound on this or provide links to where you saw this? I'm curious to know more.

I was under the impression that any doc can bill anything and get the full reimbursement amount. ie. FM excision = Derm excision = same reimbursement. Also I thought PA/NP with MD oversight can bill 100%?

Depends where you practice. Different rules for different insurances in different regions.

At our practice, the midlevel issue is that it requires direct MD oversight (i.e. they have to be pulled into the room to speak with the patient) to be reimbursed at 100% of the fee schedule

 

[ERDOC555]

Thanks for the replies. I didn't realize that there was such variability between states and even carriers. Probably a good thing to keep in mind for the future when deciding where to practice,

 

[MOHS_01]

Few things warm the heart like reading some young’n explaining how easy it is to make some fat cash.

 

[MOHS_01]

derm seems to be getting a lot of competition? PAs and NPs now can do a lot of things they do? I was just in family medicine and one of our attendings and her friend do almost everything a dermatologist does including excisions EXCEPT Moh's surgery. what do people think abbout that?

It has always been that way, most likely. Skin procedures are considered simple, low risk, and high reimbursement - and compared to a 30 minute E&M trying to talk Billy into cutting back on the ho-hos after his second toe amputation and smoking sessation after his third COPD exacerbation, conversations already had a dozen times, I suppose it is. The two real questions that need to be asked, though, are this: are they doing it as well and should they be paid equally for it. You want to step on some sensitive toes, ask those questions.