Capping Medicare

[Sushirolls]

I know large non-profit health systems and other non-profits can't cap their medicare patient numbers.

Private, for profit doctors offices can, if I remember correctly?

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[Jules A]

I believe you can. There is also the option to opt out of medicare completely in which case you are able to accept cash payments from medicare patients. I'm unable to opt out due to hospital affiliations so at my out of network practice I don't take any medicare patients.

 

[splik]

Correct - individual physicians who opt into medicare are not required to see every medicare patient that seeks an appointment. Personally I wouldn't recommend officially thinking of it as a cap and never tell patients that is why you aren't seeing them (you are not required to give patients a reason why you aren't seeing them but you can literally decline to accept a patient for any reason). However if you have more than a 100 patients or earn more than $30 000/yr from medicare patients you have to participate in MACRA/MIPS, so solo physician practices should stay below these numbers (its a nuisance and near impossible without an EMR). I kinda wish more psychiatrists would accept some medicare patients. In my experience they are slower to pay than commercial insurances but they reliably pay. I frequently get some denials of payment from commercial insurances but have not had this for Medicare. Medicare also reliably pays for prolonged services code which has not been my experience with commerical insurances. For initial evaluations I spent over 2hrs with patients and spend 30-60minutes reviewing records. For medicare patients this works out at about $650 which is not terrible by any stretch of the imagination.

 

[calvnandhobbs68]

Correct - individual physicians who opt into medicare are not required to see every medicare patient that seeks an appointment. Personally I wouldn't recommend officially thinking of it as a cap and never tell patients that is why you aren't seeing them (you are not required to give patients a reason why you aren't seeing them but you can literally decline to accept a patient for any reason). However if you have more than a 100 patients or earn more than $30 000/yr from medicare patients you have to participate in MACRA/MIPS, so solo physician practices should stay below these numbers (its a nuisance and near impossible without an EMR). I kinda wish more psychiatrists would accept some medicare patients. In my experience they are slower to pay than commercial insurances but they reliably pay. I frequently get some denials of payment from commercial insurances but have not had this for Medicare. Medicare also reliably pays for prolonged services code which has not been my experience with commerical insurances. For initial evaluations I spent over 2hrs with patients and spend 30-60minutes reviewing records. For medicare patients this works out at about $650 which is not terrible by any stretch of the imagination.

That's a pretty solid per hour rate if they actually pay that out reliably.

 

[MLT2MT2DO]

Correct - individual physicians who opt into medicare are not required to see every medicare patient that seeks an appointment. Personally I wouldn't recommend officially thinking of it as a cap and never tell patients that is why you aren't seeing them (you are not required to give patients a reason why you aren't seeing them but you can literally decline to accept a patient for any reason). However if you have more than a 100 patients or earn more than $30 000/yr from medicare patients you have to participate in MACRA/MIPS, so solo physician practices should stay below these numbers (its a nuisance and near impossible without an EMR). I kinda wish more psychiatrists would accept some medicare patients. In my experience they are slower to pay than commercial insurances but they reliably pay. I frequently get some denials of payment from commercial insurances but have not had this for Medicare. Medicare also reliably pays for prolonged services code which has not been my experience with commerical insurances. For initial evaluations I spent over 2hrs with patients and spend 30-60minutes reviewing records. For medicare patients this works out at about $650 which is not terrible by any stretch of the imagination.

3 hours of work for $650, is pretty close to terrible. I guess this is all relative

 

[dl2dp2]

What's the prolonged service code?

Also I'm not seeing your numbers. 99205 + 99354 only gives ~ $400

Another way to skin the cat is to charge a membership fee for Medicare patients to bring the total input to somewhat more parity with your commercial patients. This is 100% legal but appropriate disclosures need to be made, and I suspect will be how private psychiatry will live in the unlikely event Medicare for All goes through Congress.

 

[finalpsychyear]

Correct - individual physicians who opt into medicare are not required to see every medicare patient that seeks an appointment. Personally I wouldn't recommend officially thinking of it as a cap and never tell patients that is why you aren't seeing them (you are not required to give patients a reason why you aren't seeing them but you can literally decline to accept a patient for any reason). However if you have more than a 100 patients or earn more than $30 000/yr from medicare patients you have to participate in MACRA/MIPS, so solo physician practices should stay below these numbers (its a nuisance and near impossible without an EMR). I kinda wish more psychiatrists would accept some medicare patients. In my experience they are slower to pay than commercial insurances but they reliably pay. I frequently get some denials of payment from commercial insurances but have not had this for Medicare. Medicare also reliably pays for prolonged services code which has not been my experience with commerical insurances. For initial evaluations I spent over 2hrs with patients and spend 30-60minutes reviewing records. For medicare patients this works out at about $650 which is not terrible by any stretch of the imagination.

Hi. its over 200 patients and 90k charges since it was updated in 2019. You can also refuse to do mips and take the penalty of 10% in 2020.

How MIPS Eligibility is Determined Intro - QPP

qpp.cms.gov

 

[finalpsychyear]

What's the prolonged service code?

Also I'm not seeing your numbers. 99205 + 99354 only gives ~ $400

Another way to skin the cat is to charge a membership fee for Medicare patients to bring the total input to somewhat more parity with your commercial patients. This is 100% legal but appropriate disclosures need to be made, and I suspect will be how private psychiatry will live in the unlikely event Medicare for All goes through Congress.

The only advantage of having medicare patients who also come with a secondary insurance is reliable payments. They are usually far more complex and on pages of medications in my experience. Most providers in my area practice ageism specifically accepting patients from 19 to 55 only private insurance without any serious psych hx or dx.

 

[TexasPhysician]

3 hours of work for $650, is pretty close to terrible. I guess this is all relative

That’s much more than the typical psychiatrist nets/hour, but Ill assume a practice that takes Medicare and other lower paying insurances has high overhead.

 

[splik]

What's the prolonged service code?

Also I'm not seeing your numbers. 99205 + 99354 only gives ~ $400

Another way to skin the cat is to charge a membership fee for Medicare patients to bring the total input to somewhat more parity with your commercial patients. This is 100% legal but appropriate disclosures need to be made, and I suspect will be how private psychiatry will live in the unlikely event Medicare for All goes through Congress.

99025+99354+99355+99358

 

[michaelrack]

I would assume that you're responsible for paying taxes in the state that you're physically located in rather than the state that the patient is in. This is how things work with nearly every other kind of transaction and I have no idea why telemedicine would be different (and if it were, I would assume we would have heard about it).

That’s much more than the typical psychiatrist nets/hour, but Ill assume a practice that takes Medicare and other lower paying insurances has high overhead.

If you net that amount you're doing well, if you gross that amount, it depends ... you're probably making a decent living

 

[Mass Effect]

99025+99354+99355+99358

I didn't even know two of those codes existed. Can someone point me in the direction of a great comprehensive primer on CPT codes and what I can legally bill together? I almost always bill only one.

 

[Sushirolls]

Don't get too excited, almost none of the private insurance companies pay for 99354. Those codes will get reimbursed by medicare, but they also require lengthy documentation at the end of your note. More than "greater than 50% was spent in counseling/coordination of care..."

I recently had one, ONE, company pay for a 99354 code, and they also requested my chart notes to see that everything checked out. Actually got paid for it, too. But don't count on it.

 

[NickNaylor]

I didn't even know two of those codes existed. Can someone point me in the direction of a great comprehensive primer on CPT codes and what I can legally bill together? I almost always bill only one.

I made a cheat sheet of commonly used codes, wRVUs that they provide (at least as of 2019), and a very short description of requirements for each. It doesn't cover everything, but it covers codes that I most commonly use in the settings that I work in (inpatient, outpatient, and ED). I spent a good amount of time tracking everything down and I haven't had our billing folks harass me about anything being wrong yet, so I'm fairly sure it's accurate.

You can check it out here: Box

 

[Psych19]

I made a cheat sheet of commonly used codes, wRVUs that they provide (at least as of 2019), and a very short description of requirements for each. It doesn't cover everything, but it covers codes that I most commonly use in the settings that I work in (inpatient, outpatient, and ED). I spent a good amount of time tracking everything down and I haven't had our billing folks harass me about anything being wrong yet, so I'm fairly sure it's accurate.

You can check it out here: Box

That's a nice summary of billing codes. I don't think your comment about a level 2 hospital discharge (99239) requiring more than 30 minutes face-to-face is accurate. You can also include time spent providing discharge services that are not face-to-face. I.e., you can also count time spent providing instructions to caregivers and time spent preparing discharge prescriptions, referrals, and discharge records.

Discharge Services - The Hospitalist

Fundamentals paramount to discharge day management service billing

www.the-hospitalist.org

 

[clausewitz2]

I made a cheat sheet of commonly used codes, wRVUs that they provide (at least as of 2019), and a very short description of requirements for each. It doesn't cover everything, but it covers codes that I most commonly use in the settings that I work in (inpatient, outpatient, and ED). I spent a good amount of time tracking everything down and I haven't had our billing folks harass me about anything being wrong yet, so I'm fairly sure it's accurate.

You can check it out here: Box

Worth mentioning that come January 1st of next year the standards for the outpatient E&M codes for different levels of complexity are changing significantly. Go down to page 7 here:

https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf

Good news is, fewer garbage reviews of systems and physical exams need to be documented. Also, it will be trivial for most of our patients to be 99214. 99215 looks like it is going to be difficult for folks not part of a large system or who don't have access to a big system's EMR because you really need to be reviewing external notes/testing. However, basically everyone on clozapine or lithium is a 99215 now, so that's good. I am guessing we are going to see a huge upswing in the degree of fidelity and care outpatient psychiatrists take in ordering annual metabolic labs on literally everyone who could ever possibly need them.

 

[NickNaylor]

That's a nice summary of billing codes. I don't think your comment about a level 2 hospital discharge (99239) requiring more than 30 minutes face-to-face is accurate. You can also include time spent providing discharge services that are not face-to-face. I.e., you can also count time spent providing instructions to caregivers and time spent preparing discharge prescriptions, referrals, and discharge records.

Discharge Services - The Hospitalist

Fundamentals paramount to discharge day management service billing

www.the-hospitalist.org

Everything that I've seen re: discharge codes is that 99239 requires documenting >30 minutes of time spent "coordinating care." I agree that that time doesn't necessarily have to be face-to-face with the patient - I will include time spent talking with family, outpatient providers, etc. in that time - and I suppose you could try billing it without documenting time spent on the day of discharge, but considering it's such a small point to document I don't see the point of not including that documentation in a discharge note.

 

[MLT2MT2DO]

That’s much more than the typical psychiatrist nets/hour, but Ill assume a practice that takes Medicare and other lower paying insurances has high overhead.

Agreed, but this is gross as you mentioned. Even with all the fancy note fluff and billing codes still doesn't touch most private pay insurances, add onto the fact that Splik sees some complicated cases with multiple comorbidities. I think it's great taking on Medicare patients but I wouldn't say they pay "well" in MOST circumstances and would see why people would inquire about the ability to cap.

 

[Mass Effect]

I made a cheat sheet of commonly used codes, wRVUs that they provide (at least as of 2019), and a very short description of requirements for each. It doesn't cover everything, but it covers codes that I most commonly use in the settings that I work in (inpatient, outpatient, and ED). I spent a good amount of time tracking everything down and I haven't had our billing folks harass me about anything being wrong yet, so I'm fairly sure it's accurate.

You can check it out here: Box

Thank you kind sir.

 

[Jules A]

Has there ever been any talk of loosening up the no out of network payments for medicare unless the provider has completely opted out? Why would they care if the patient pays out of pocket? Its not like it is a low income program or if the person submits for out of network benefits that it will cost more. In my experience many cash patients don't bother submitting at all.

 

[TexasPhysician]

Has there ever been any talk of loosening up the no out of network payments for medicare unless the provider has completely opted out? Why would they care if the patient pays out of pocket? Its not like it is a low income program or if the person submits for out of network benefits that it will cost more. In my experience many cash patients don't bother submitting at all.

No. The government’s goal is for everyone to be in-network with Medicare. This benefits the elderly that turns out most at the polls.

 

[Sushirolls]

Has there ever been any talk of loosening up the no out of network payments for medicare unless the provider has completely opted out? Why would they care if the patient pays out of pocket? Its not like it is a low income program or if the person submits for out of network benefits that it will cost more. In my experience many cash patients don't bother submitting at all.

As long as medicare (CMS) can hold over organizations their non-profit status as contingent upon accepting Medicare, they have no incentive to permit this type of balance billing. Its possible finances might tip in favor of dropping CMS for large organization, especially as their is a race to the bottom currently being seen by United Healthcare and others (go see the anesthesia/EM forums).

And considering the current 'click bait' media hype on balance billing and pursuits to stamp it out, the odds are less such a system will emerge.

It's also even more entrenched the current system with majority of states as CON (certificate of need) which comes with requirement to also accept CMS as part of the obtaining the certificate. So as you can see, in one way or another hospitals and facilities are controlled by CMS. If you drop CMS in network status, you not only risk losing the non-profit status, but also the state CON, and could get shut down.

*All more the reason the lurking med students reading should pay attention to the benefits of picking a heavy outpatient specialty like FM/IM/Psych which allows you the escape from hospital bureaucracy.

 

[Jules A]

It makes sense but since there will always be the concierge minded patients who want the level of service and can pay out of pocket that would make a small dent in both access and Medicare's outlay. I get them wanting to force everyone to accept it but for small private practice psychiatrists who are not willing to completely opt out it reduces access to care for those with Medicare who want to pay out of pocket.