tommyj45 said:
I am stuck! I am an undergrad premed doing research with a hepatologist as my PI. We are doing a cost/effectiveness study. I am supposed to start writing the paper next week to send off for publication, BUT I don't have all my data. Does anybody happen to know how physicians bill their cash paying patients and how the HMOs decide compensations? I need simple costs like comprehensive metabolic panels, checking liver enzymes CBC, bun etc. Also the actual clinical cost of a GI visit and Onc visit. Any help would be incredibly appreciated. Thanks!
These costs will vary widely with geography, type of practice environment, procedures performed.
There are several sets of billing codes involved. The ones most pertinent to you are the Evaluation and Management Codes which are in common use by Medicare and therefore the HMOs. The codes you are interested in are 99212 range. These codes are divided into new patients v. established patients. A low level code is an established patient problem focused visit. CMS (Center for Medicare/Medicaid Services) sets the standards for which code you use for billing Medicare.. This code is multiplied by a value called the Relative value (RBRVU) which according to the government for what that's worth, takes into acount, among other things, the nature of the specialist, the amount of work, the practice expenses and a whole bunch of magic that only governmental accountants, actuaries and others with red horns, long pointied tails and pitchforks sitting in piles of brimstone (I think they're called politicians) comprehend. Then the HMO will make you send in a 4 page justification for a simple procedure.
The E&M codes also have modifiers which further complicate things. So, you never know what the HMO is going to pay you until after you bill them. For primary docs, they pay what is known as a "capitated" amount. This is a fixed amount whether you see a patient once or a hundred times.
These rates all vary with practice, specialty and location. They are negotiated between the docs and the payers and unfortunately for you, docs can't discuss these rates among themselves, due to anti-trust rules.
As for cash payers, each physician group or practice has a fee schedule for each of the codes/modifiers/procedures done. Again, these are not secrets, but they cannot be shared among docs.
Probably the quickest and easiest way to find out what a cash payer will pay is to call a specialist's office, ask them what they charge, explaining you're doing research and promising them you won't use their data in any individually identifiable way. Another source is to go to the specialty boards and ask them. The ACR lists the RBRVS multipliers and some codes of importance to the College. I don't know if others do.
Good luck. The data are variable and somewhat hard to come by. My annual physicals are not covered by my insurance. I pay $75 for the H&P/exam exclusive of labs, studies, imaging etc. for an established patient well visit cash payer. Others I know who use the same doc in similar circumstances have paid more. In my clinic (specialty) the going rate for an e&m established is around $300 and I have no idea how much of that actually shows up in the receipts, but I suspect it is much less than 100%.
