Contract negotiations with insurance

[AttackNME]

Wondering if anyone can share their experience who have had success? How did you do it? Did you hire a consultant? I think this will help a lot of people, thanks in advance!

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[ExperiencedDPM]

Wondering if anyone can share their experience who have had success? How did you do it? Did you hire a consultant? I think this will help a lot of people, thanks in advance!

I personally have never seen this happen. Even with large groups. Unfortunately, unless you are the only provider in the area, it’s likely they will simply default to those who do accept their fees.

The only exception I can imagine is if you have a unique skillset and they need you to provide this service to their patients.

I’ve seen HUGE urology and cardiology groups negotiate, but I am personally unaware of any DPMs having success negotiating.

Of course that doesn’t mean it’s not possible.

 

[heybrother]

I've attempted. It didn't work.

-I had a 65% E&M/75% CPT contract with Humana. I had 7-8 phonecalls with them trying to acquire my contract and get someone on the phone to discuss our rates. The people on the other end were purposely incompetent. I'd get tracking numbers and what not for the phonecalls and the next person to look would say the last person left the log entry blank and they had no record or notes. I ultimately got someone to indicate they'd contact the rates department. I received an email. It was 1 word. The word was "no". Literally nothing else. I replied to the email politely explaining that I had an enormous number of their patients, that I had what I thought was a valuable skill set in that I tag teamed a lot of wounds with one of the local hospitals WHCs, that I was the only podiatrist in town who did ankle surgery, the only podiatrist who routinely did fusions etc, that I am in a fairly remote area with a low number of providers etc. They replied offering to merge my rates to 70%. I didn't write back. I suffered for another year and dropped them. They never contacted us or tried to get us to stay. A whole bunch of the local employers that offered "lifetime health insurance" to retirees were paying for Humana but they switched to United which meant we didn't really lose any patients. Once we dropped- the handful of patients we saw with Humana had to pay out of network copay (from like $40->65). However, we then got paid at 100% of Medicare. I would describe dropping as one of the best things we ever did. No more 65% encounters (pathetic). Humana routinely refuses to pay for 11056 +11720 when together. You can try to fight it but you'll probably have to appeal up to an ALJ. If you have any sort of care occurring in a global ie. you do an amputation on one foot but have an ulcer on the other - they won't cover it. We could continue to see their patients out of network but somehow this became too confusing for my partner - he told the front desk to turn away anyone with Humana. My desk is near our front desk and I routinely hear Humana people crying on the phone saying there's no one who will see them / they can't get in anywhere.

-Aside, I spoke to an IPA who showed me some of their paperwork. Podiatrists were specifically called out in it as "physician extenders" by Humana with lower rates than all other physicians for both commercial and MA.

-I've written about this elsewhere / asking for otheres experience etc - but it seems if a patient has a Medicare advantage plan + out of network benefits + and is willing to pay the out of network copay (and possibly higher coinsurance) - not being in network means you potentially can get 100% of Medicare if they are offering crappier rates in network.

-Bizarrely, I had a market place plan call me wanting to discuss my rates. They offered me 125% of Medicare. This was surprising to me because I was receiving substantially higher than this even though I had no memory of signing a contract - we were getting like 160%+. I told them we wouldn't be signing anything as our current rates were better than what they were offering. They didn't write back and we are still getting paid those rates. Unfortunately I see 5-10 patients a year with this insurance. Take home lesson is - know your rates. People will apparently try to talk you into taking a paycut.

-I won't get into the details but I had another plan where I tried the online recommendation. The recommendation of the internet is don't ask for a big rate shift - propose a few codes you'd like to change. The story is too long to tell - but an insurance has cut my rates because I asked for a rate increase. Our in office rates went up (mostly) but our surgical rates got cut to pieces. It takes a lot of improved 99213s to make up for losing $700 on a lapidus. We'll see how this one ends. The punch in the face here is the small local company got bought by a big state company but the state company stuck with the small company rates.

-Reached out to United. My partner didn't bother reading the contract where our United rates were cut to pieces. I was told "it was a renewal and we just need to sign it". It wasn't. it was a massive cut locked in for 3 years. We went from Medicare-positive for CPT to sub-Medicare. I asked to discuss rates. They wrote back and said - your contract is for 3 years and you aren't eligible. Contact us in 2.75 years or whatever to discuss your rates for the next contract. I can drop them in April if I notify them in January. Most insurances will allow you to terminate the contract with 3 months notice. United contracts are 3 years and if I understand it can only be dropped on anniversaries of the contract with 3 months notification.

-A United subsidiary send me a contract offering to increase my United Medicare Advantage rate by 10% when I see a patient for their specific United branch. I asked for 100% of Medicare. They said they couldn't. I told them I only have 1 patient with their insurance who is a regular and that I'd be dropping them in a few months when I dropped United. I don't need one little United contract fixed. You could argue I'm leaving money on the table here but either the whole contract gets fixed when we notify or we terminate and go out of network. Not really clear why they reached out to me to begin with. I wonder/suspect that they are trying to get set-up as a MA plan in our area and somehow need to demonstrate that there are enough providers but I don't know.

-Was reviewing rates for my office for some small local plans. I noted that we were receiving very poor rates from a specific insurance. Namely - everything we were paid was 60% of our charges. We have very reasonable fee schedules - I suppose 60% of a huge number would be fine but we don't do the huge numbers game. I had my office manager call the insurance. They immediately offer us 135% of Medicare. Interestingly, they claimed to offer 135% of the "non-facility" rate regardless of where the procedure was performed. That means you use the in office Austin/Lapidus/1st MPJ rates. Anyway, we sign the contract and they -NEVER- paid us the contracted rate. I made an excel of a bunch of claims saying - hey you aren't paying us right. Then they said - oh sorry, we have multiple plans and we only fixed your rates for some of the plans. We'll get to work on that. Anyway, have never been paid appropriately at the contracted rate on anything. Interestingly, the IPA I discuss below has ever better rates than I do but ...who knows if we'll ever get paid.

-I reached out to a large IPA. I sign a non-disclosure. They offer to allow me to send requests for like 5 codes. They tell me that Aetna and United essentially don't negotiate. Kind of annoying foot dragging - the person I spoke to went out of town blah blah. Anyway, my most common insurance plan rates were identical to theirs. One of their rates was dramatically less than mine. Two of their contracts were better than me personally by like a dollar a code but for one of those contracts was dramatically less than what my partner receives. One of the plans they sent rates ...but I know the insurance in question has 2 rates and the 2nd rate is top tier/amazing - am I going to lose the top rate if I sign with them? This was sort of a wtf moment for me because most of the people who post on this forum seem really happy about their IPA situation while these guys rates weren't really any better than what I have. I sort of wonder - if an IPA is too large or too spread out does it essentially lose power or perhaps its goal is really just to get people in network - not to negotiate for them.

-I reached out to my local IPA. I had reached out to them in the past but they never returned my calls. Called them again and I guess they had some turn over or something. Anyway, for one of my semi-common plansts their rates are DRAMATICALLY better than my rates. Not a massively common plan but a substantial improvement that will pay for itself in a few patients. Their BCBS rates might...maybe... we'll see be better than ours. They apparently can't share BCBS without my joining the IPA so that will be one of those little surprises. Unfortunately, no one cares about rates like you and I care about rates. They initially sent me some sort of old BCBS contract. I said - this can't be your rates. If it is you are being paid less than I am. They ultimately agreed it was wrong/old. They also have better rates with a lot of small local indemnity type plans - some quite substantially. However, I checked and we aren't seeing 25 people with these plans a year but seeing even a few of these patients would pay for the IPA fee. The heart of this again is - know your rates. It appears I'm going to substantially improve 1 plan. If I somehow improve my BCBS rate though it will be a win.


1. A lot of insurances won't negotiate.
2. ...even if you are big. One of the local hospitals dropped Aetna and only then did Aetna negotiate. I doubt they'd show me the same courtesy.
3. Know your rates. You can't talk about rates if you don't know what you are already getting.
4. The internet says focus on your most common codes or your worse codes. Didn't work for me. Your mileage may vary.
5. The internet also says focus on your worst plans. My opinion - your bad plans are bad for a reason. The only strength you have with them is to drop them.
6. Just because its an IPA doesn't mean its better than what you already have. Gotta check to the best of your ability line by line. That said, IPAs still seem to be the best path forwards for improving rates.
7. Feli suggested elsewhere that your best bet with an IPA is to improve 1-2 plan rates. Seems reasonable to me since best case I'm going to improve 2 common insurances + a smattering of small ones.
8. Medicare Advantage plans with bad rates + out of network benefits can pay 100% if you aren't in network. My limited experience. If I success in this strategy against United I will laugh my ass off.
9. If you sign a contract make sure they are actually paying the contracted rate.
10. I still can't teach you anything about "out of network commercial billing". Theoretically though you can balance bill these patients.
11. If you do a lot of hospital work and try to go out of network you may find yourself facing the No Surprises Act.
12. There are people out there getting large positive multipliers from commercial insurances and my god, it must be amazing.
13. Small aside - I really only have a handful of contracts that pay the Medicare 2021 E&M change rates ie. almost all commercial insurances pay less than a Medicare 99213 and most pay substantially less.
14. Sit down and do the math. If you replace 2 sub-Medicare United visits with hell - 1 commercial BCBS 99203+11750 that you fit in as a same day you are likely substantially ahead on revenue with less work.

 

[deleted285117]

You win award for longest post ever. Even longer than any of @Feli ’s 😱

 

[heybrother]

You win award for longest post ever. Even longer than any of @Feli ’s 😱

Feli comes back after and modifies his posts to make them even longer. Oh wait. There's more!

Forgot - small thing

If you somehow find yourself actually negotiating - always ask for more. While the overall negotiations were not successful - on 3 occasions where someone negotiated - asking for more increased the offer by 10%.

-The people who offered 125% initially offered 115%. We declined and they increased.
-A plan offered a 5% increase to a MA rate. We said it wasn't enough and they offered 10%.
-Another plan offered 100% of Medicare and 90% for imaging. We declined and they offered 110% for both.

In short - always ask for more. I don't think you'll go from 150 to 200% but you might go from 90 to 100%.

 

[619]

14. Sit down and do the math. If you replace 2 sub-Medicare United visits with hell - 1 commercial BCBS 99203+11750 that you fit in as a same day you are likely substantially ahead on revenue with less work.

This is the reason I always say seeing 40+ patients a day is not any better than seeing 20 a day. In this day and age, more patient volume does not automatically mean increase in revenue. In fact I bet more volume will cause revenue to flatline or even decrease when you are rushing going from room to room just to stay on time.

Once you clear up your schedule and drop the sub-medicare plans, limit the medicaid or state plans and then you work less, see less patients and revenue will be the same or even go up because you are now spending more time with your high paying patients and treating more pathologies that you could have missed or ignored when you have 40+ patients a day and you are naturally rushing from room to room.

My sweet spot is 20 patients a day. Up to 24 if it is a holiday week like thanksgiving.

 

[air bud]

I've attempted. It didn't work.

-I had a 65% E&M/75% CPT contract with Humana. I had 7-8 phonecalls with them trying to acquire my contract and get someone on the phone to discuss our rates. The people on the other end were purposely incompetent. I'd get tracking numbers and what not for the phonecalls and the next person to look would say the last person left the log entry blank and they had no record or notes. I ultimately got someone to indicate they'd contact the rates department. I received an email. It was 1 word. The word was "no". Literally nothing else. I replied to the email politely explaining that I had an enormous number of their patients, that I had what I thought was a valuable skill set in that I tag teamed a lot of wounds with one of the local hospitals WHCs, that I was the only podiatrist in town who did ankle surgery, the only podiatrist who routinely did fusions etc, that I am in a fairly remote area with a low number of providers etc. They replied offering to merge my rates to 70%. I didn't write back. I suffered for another year and dropped them. They never contacted us or tried to get us to stay. A whole bunch of the local employers that offered "lifetime health insurance" to retirees were paying for Humana but they switched to United which meant we didn't really lose any patients. Once we dropped- the handful of patients we saw with Humana had to pay out of network copay (from like $40->65). However, we then got paid at 100% of Medicare. I would describe dropping as one of the best things we ever did. No more 65% encounters (pathetic). Humana routinely refuses to pay for 11056 +11720 when together. You can try to fight it but you'll probably have to appeal up to an ALJ. If you have any sort of care occurring in a global ie. you do an amputation on one foot but have an ulcer on the other - they won't cover it. We could continue to see their patients out of network but somehow this became too confusing for my partner - he told the front desk to turn away anyone with Humana. My desk is near our front desk and I routinely hear Humana people crying on the phone saying there's no one who will see them / they can't get in anywhere.

-Aside, I spoke to an IPA who showed me some of their paperwork. Podiatrists were specifically called out in it as "physician extenders" by Humana with lower rates than all other physicians for both commercial and MA.

-I've written about this elsewhere / asking for otheres experience etc - but it seems if a patient has a Medicare advantage plan + out of network benefits + and is willing to pay the out of network copay (and possibly higher coinsurance) - not being in network means you potentially can get 100% of Medicare if they are offering crappier rates in network.

-Bizarrely, I had a market place plan call me wanting to discuss my rates. They offered me 125% of Medicare. This was surprising to me because I was receiving substantially higher than this even though I had no memory of signing a contract - we were getting like 160%+. I told them we wouldn't be signing anything as our current rates were better than what they were offering. They didn't write back and we are still getting paid those rates. Unfortunately I see 5-10 patients a year with this insurance. Take home lesson is - know your rates. People will apparently try to talk you into taking a paycut.

-I won't get into the details but I had another plan where I tried the online recommendation. The recommendation of the internet is don't ask for a big rate shift - propose a few codes you'd like to change. The story is too long to tell - but an insurance has cut my rates because I asked for a rate increase. Our in office rates went up (mostly) but our surgical rates got cut to pieces. It takes a lot of improved 99213s to make up for losing $700 on a lapidus. We'll see how this one ends. The punch in the face here is the small local company got bought by a big state company but the state company stuck with the small company rates.

-Reached out to United. My partner didn't bother reading the contract where our United rates were cut to pieces. I was told "it was a renewal and we just need to sign it". It wasn't. it was a massive cut locked in for 3 years. We went from Medicare-positive for CPT to sub-Medicare. I asked to discuss rates. They wrote back and said - your contract is for 3 years and you aren't eligible. Contact us in 2.75 years or whatever to discuss your rates for the next contract. I can drop them in April if I notify them in January. Most insurances will allow you to terminate the contract with 3 months notice. United contracts are 3 years and if I understand it can only be dropped on anniversaries of the contract with 3 months notification.

-A United subsidiary send me a contract offering to increase my United Medicare Advantage rate by 10% when I see a patient for their specific United branch. I asked for 100% of Medicare. They said they couldn't. I told them I only have 1 patient with their insurance who is a regular and that I'd be dropping them in a few months when I dropped United. I don't need one little United contract fixed. You could argue I'm leaving money on the table here but either the whole contract gets fixed when we notify or we terminate and go out of network. Not really clear why they reached out to me to begin with. I wonder/suspect that they are trying to get set-up as a MA plan in our area and somehow need to demonstrate that there are enough providers but I don't know.

-Was reviewing rates for my office for some small local plans. I noted that we were receiving very poor rates from a specific insurance. Namely - everything we were paid was 60% of our charges. We have very reasonable fee schedules - I suppose 60% of a huge number would be fine but we don't do the huge numbers game. I had my office manager call the insurance. They immediately offer us 135% of Medicare. Interestingly, they claimed to offer 135% of the "non-facility" rate regardless of where the procedure was performed. That means you use the in office Austin/Lapidus/1st MPJ rates. Anyway, we sign the contract and they -NEVER- paid us the contracted rate. I made an excel of a bunch of claims saying - hey you aren't paying us right. Then they said - oh sorry, we have multiple plans and we only fixed your rates for some of the plans. We'll get to work on that. Anyway, have never been paid appropriately at the contracted rate on anything. Interestingly, the IPA I discuss below has ever better rates than I do but ...who knows if we'll ever get paid.

-I reached out to a large IPA. I sign a non-disclosure. They offer to allow me to send requests for like 5 codes. They tell me that Aetna and United essentially don't negotiate. Kind of annoying foot dragging - the person I spoke to went out of town blah blah. Anyway, my most common insurance plan rates were identical to theirs. One of their rates was dramatically less than mine. Two of their contracts were better than me personally by like a dollar a code but for one of those contracts was dramatically less than what my partner receives. One of the plans they sent rates ...but I know the insurance in question has 2 rates and the 2nd rate is top tier/amazing - am I going to lose the top rate if I sign with them? This was sort of a wtf moment for me because most of the people who post on this forum seem really happy about their IPA situation while these guys rates weren't really any better than what I have. I sort of wonder - if an IPA is too large or too spread out does it essentially lose power or perhaps its goal is really just to get people in network - not to negotiate for them.

-I reached out to my local IPA. I had reached out to them in the past but they never returned my calls. Called them again and I guess they had some turn over or something. Anyway, for one of my semi-common plansts their rates are DRAMATICALLY better than my rates. Not a massively common plan but a substantial improvement that will pay for itself in a few patients. Their BCBS rates might...maybe... we'll see be better than ours. They apparently can't share BCBS without my joining the IPA so that will be one of those little surprises. Unfortunately, no one cares about rates like you and I care about rates. They initially sent me some sort of old BCBS contract. I said - this can't be your rates. If it is you are being paid less than I am. They ultimately agreed it was wrong/old. They also have better rates with a lot of small local indemnity type plans - some quite substantially. However, I checked and we aren't seeing 25 people with these plans a year but seeing even a few of these patients would pay for the IPA fee. The heart of this again is - know your rates. It appears I'm going to substantially improve 1 plan. If I somehow improve my BCBS rate though it will be a win.


1. A lot of insurances won't negotiate.
2. ...even if you are big. One of the local hospitals dropped Aetna and only then did Aetna negotiate. I doubt they'd show me the same courtesy.
3. Know your rates. You can't talk about rates if you don't know what you are already getting.
4. The internet says focus on your most common codes or your worse codes. Didn't work for me. Your mileage may vary.
5. The internet also says focus on your worst plans. My opinion - your bad plans are bad for a reason. The only strength you have with them is to drop them.
6. Just because its an IPA doesn't mean its better than what you already have. Gotta check to the best of your ability line by line. That said, IPAs still seem to be the best path forwards for improving rates.
7. Feli suggested elsewhere that your best bet with an IPA is to improve 1-2 plan rates. Seems reasonable to me since best case I'm going to improve 2 common insurances + a smattering of small ones.
8. Medicare Advantage plans with bad rates + out of network benefits can pay 100% if you aren't in network. My limited experience. If I success in this strategy against United I will laugh my ass off.
9. If you sign a contract make sure they are actually paying the contracted rate.
10. I still can't teach you anything about "out of network commercial billing". Theoretically though you can balance bill these patients.
11. If you do a lot of hospital work and try to go out of network you may find yourself facing the No Surprises Act.
12. There are people out there getting large positive multipliers from commercial insurances and my god, it must be amazing.
13. Small aside - I really only have a handful of contracts that pay the Medicare 2021 E&M change rates ie. almost all commercial insurances pay less than a Medicare 99213 and most pay substantially less.
14. Sit down and do the math. If you replace 2 sub-Medicare United visits with hell - 1 commercial BCBS 99203+11750 that you fit in as a same day you are likely substantially ahead on revenue with less work.

This it's crazy that you have to deal with this type of stuff as well as actually seen and treating patients. Trying to remember do you guys have a practice manager?

Fortunately you have all the advanced training from Podiatry school and residency to fall back on to help you navigate all of this

 

[heybrother]

This it's crazy that you have to deal with this type of stuff as well as actually seen and treating patients. Trying to remember do you guys have a practice manager?

Fortunately you have all the advanced training from Podiatry school and residency to fall back on to help you navigate all of this

We have an office manager. They do a number of vitals tasks but I only trust myself with fee schedule stuff. I can't claim any sort of substantial life changing degree of success at it, but I at least know what I'm getting when someone talks numbers with us.

I don't even want to guess how much time I've put into fee schedule related tasks. I will say what will crush you is to look back through time and see how Medicare's fee schedule has changed through time. There's some literature in orthopedics discussing how foot and ankle codes have been crushed.

I mentioned the other day that in 2016 we were getting $349 or something like that for a 11750. The reason for that is because in 2013 or something like that the Medicare fee schedule for a 11750 was dramatically higher (its under $160 for me currently and was like $213 in 2013). One of the IPAs I spoke to had 2001 Medicare fee schedule values as the basis for some rates (large multiplier). Interestingly, some of our common codes were substantially more valuable in 2011. 20550 was worth $87 then and is worth like $53 now. But yeah - I literally pulled all the fee schedules for 2001 for all the codes my office had used over the last 2 years to see what we'd be looking at if our values were based on that.

 

[AttackNME]

We have an office manager. They do a number of vitals tasks but I only trust myself with fee schedule stuff. I can't claim any sort of substantial life changing degree of success at it, but I at least know what I'm getting when someone talks numbers with us.

I don't even want to guess how much time I've put into fee schedule related tasks. I will say what will crush you is to look back through time and see how Medicare's fee schedule has changed through time. There's some literature in orthopedics discussing how foot and ankle codes have been crushed.

I mentioned the other day that in 2016 we were getting $349 or something like that for a 11750. The reason for that is because in 2013 or something like that the Medicare fee schedule for a 11750 was dramatically higher (its under $160 for me currently and was like $213 in 2013). One of the IPAs I spoke to had 2001 Medicare fee schedule values as the basis for some rates (large multiplier). Interestingly, some of our common codes were substantially more valuable in 2011. 20550 was worth $87 then and is worth like $53 now. But yeah - I literally pulled all the fee schedules for 2001 for all the codes my office had used over the last 2 years to see what we'd be looking at if our values were based on that.

Thanks for sharing, you're really into this stuff and seem to know your numbers for sure. Have you considered hiring a consultant to help with negotiations?

 

[msion]

Make friends with vascular surgeons. I wrote in another post that sometimes peer recommendations will get you into an insurance plan and get you good rates. Usually works well for capitated plans. Recently I am seeing more capitated models in my area. FFS is definitely going away. Gotta adapt. In theory it may actually works well if you are in a good region. These capitated plan can be like IPAs where doctors on the panel meet to determine need for another podiatrist if you apply. So better to know who these doctors are. Usually they work in the local hospitals as well.

Never be afraid to drop an insurance. I know a lot of doctors fear that they will have no patients to see if they don't take these medicaid plans. It's not true. Sometimes you will find out you may be the only doctor taking that plan in the whole county.

 

[heybrother]

Thanks for sharing, you're really into this stuff and seem to know your numbers for sure. Have you considered hiring a consultant to help with negotiations?

Jokingly I get all of my inspirations from SDN so I'll have to look into what a consultant could do for us.

My big thing about rates is - until you talk to someone or see an IPAs rates through an NDA - you really have no idea what to expect. Like some of the rates I've been shown recently are higher than I would have ever thought to ask for based on our current rates. So if a consultant can give you insights into how plans behave across the country - that's interesting. My weird consultant problem though is (a) I'm fairly happy with my BCBS rates (could be happier but eh), (b) I'm about to be happier about another plan (c) and then after that I don't think Aetna/United negotiate... I've literally had 2 IPAs tell me they used to have rates with those payors and it all fell apart. I sort of wonder if the main benefit of consultants is just getting you onto plans or tell you owhere you stand.

 

[heybrother]

Make friends with vascular surgeons. I wrote in another post that sometimes peer recommendations will get you into an insurance plan and get you good rates. Usually works well for capitated plans. Recently I am seeing more capitated models in my area. FFS is definitely going away. Gotta adapt. In theory it may actually works well if you are in a good region. These capitated plan can be like IPAs where doctors on the panel meet to determine need for another podiatrist if you apply. So better to know who these doctors are. Usually they work in the local hospitals as well.

Never be afraid to drop an insurance. I know a lot of doctors fear that they will have no patients to see if they don't take these medicaid plans. It's not true. Sometimes you will find out you may be the only doctor taking that plan in the whole county.

So - weird thing. I theoretically have an idea of what a good plan is ie. if someone offers me FFS rates, but what is your definition of a good capitated plan?

 

[msion]

So - weird thing. I theoretically have an idea of what a good plan is ie. if someone offers me FFS rates, but what is your definition of a good capitated plan?

Profit sharing at the end of each month/quarter. For me that amount determines if it’s a good plan.

 

[Pronation]

All of this is making my head spin. I think I am just too dumb to handle anything other than RVU comp.

 

[AttackNME]

I met with a consultant today to consider hiring her to help us renegotiate our contracts. First step is to gather data of the most common Cpt codes, frequency that they’re billed, total $ billed for each Cpt, total $ collected for each Cpt, calculate collections %, and the look at the best payors. Things to help with negotiation involves being able to tell a story, why am I special, why are we different from from any other podiatry group? Example would be for example if you’re the only person in an area that provides a service. Too bad I can’t say I’m a fellowship trained foot and ankle orthoplastic neurosurgeon but I can say I’m one of the few in town who do a lot of limb salvage. Next step is if we decide to do this, to find 4-5 hours where our office staff can gather this data to present to the consultant. Will continue to report once I find out more

 

[heybrother]

I personally don't understand why they ask what you "bill for each code". There are insurances that pay a % of what you charge, but its not any of the large mainstream insurances. You can bill $1000 for a 99203 - you aren't going to get it.

My big thing when looking at data is:

(a) does your reimbursement consistently follow a pattern ie. are CPT codes consistently reimbursed at a percentage ie. 150% of Medicare or are there different values for every code. The latter complicates things. A lot of the insurances are always a few years behind so you'll see fluctuations where codes are worth 1.49 to 1.55 which suggests to me that they aren't using 2022 data but data from a few years ago where the base values have slightly drifted. That's not a big deal because it means there's still a predictable pattern. A big deal is getting 75% of Medicare for 11042 and 125% for 20550. That implies intent - that they've purposely devalued a code.

(b) Do different partners in the group get different rates?

(c) If the rates fluctuate for each provider ie. 75% for one code, 125% for another - whatever - then you need to actually ask the insurance company for a fee schedule. Many of the companies have a way for you to get this but they'll drag their feet. Cigna has a request feature that takes a week. BCBS has Availity but historically the surgical data was always slightly off.

I personally think the most logical path for looking at your reimbursement is to look at it as a percent of Medicare because in all my experiences with talking to insurance companies - the values they offer are always some version of a percentage of Medicare. ie. they'll offer X% for imaging, X% for E&M, and X% for CPT. In my area BCBS pays different rates for CPT in the office and CPT in facility so further breakdowns can be found.

Perhaps your consultant intends to try to just ask for more money for specific codes - that's what people discuss doing on the internet. I only tried this once. It didn't work out - they simply offered me a straight percentage of Medicare.

We're in a weirdly tough spot. We're entirely dependent on all aspects of our fee schedule because we perform E&M, procedures, imagery, and facility surgery. Jokingly, I would kill to just be someone who hits E&M all day. The base values for 99213 vs a lot of our codes ie. 20550, 20605, etc just crushes me. Literally a 1.5 multiplier on CPT means a 20550 is still worth less than a 99213.

Anyway. My opinion - this will take you more than 4-5 hours. Good luck!

 

[PlainsPod]

I didn’t think you Could bill E&M + procedure code on same day of service for BCBS….even if it is a new visit

 

[619]

I didn’t think you Could bill E&M + procedure code on same day of service for BCBS….even if it is a new visit

This has to be a regional thing. I bill new E&M + procedure code 100% of this time. Obviously my notes backs it up. These are separate components. I don't know how you do a procedure on a patient without first evaluating/managing the patient.

Another way insurance company tries to screw us over but oh well! Nothing new here.

 

[dtrack22]

I didn’t think you Could bill E&M + procedure code on same day of service for BCBS….even if it is a new visit

This was happening in TX years ago. I posted about it in whatever thread people were having a pissing match over insurance companies purposefully trying to not pay doctors. At that time, it wasn’t that you couldn’t bill it, it was the BCBS computer system auto-rejecting all claims with a 25 modifier and requiring appeal. Which, once submitted, would be paid when appropriate. They claimed it was a software error, but then didn’t fix it for at least 1-2 years.

 

[619]

This was happening in TX years ago. I posted about it in whatever thread people were having a pissing match over insurance companies purposefully trying to not pay doctors. At that time, it wasn’t that you couldn’t bill it, it was the BCBS computer system auto-rejecting all claims with a 25 modifier and requiring appeal. Which, once submitted, would be paid when appropriate. They claimed it was a software error, but then didn’t fix it for at least 1-2 years.

Think of the millions of $$$ BCBS saved (or made). I don't think they were ever reprimanded but then again we docs are the bad guys try to defraud them.

 

[AttackNME]

Think of the millions of $$$ BCBS saved (or made). I don't think they were ever reprimanded but then again we docs are the bad guys try to defraud them.

These MACs handle a huge amount of data, they handle every medical transaction for the region. I can see how software can be buggy and they drag their feet to fix it, but what competition do they have to take their jobs if they don't do better? The only reprimanding would come from a class action law suit I imagine. You gonna start documenting every incident that you believe insurance screwed you $$$? It might come in handy one day.

The consultant (who used to work for the payor side until she switched over to help physicians) told me that insurance companies are typically trying to figure out which doctors they want to give a pay increase to, but they wouldn't go out of their way to call someone to see if its okay to improve their contract, so this consultant recommends contract renewals to be done every 2 years. That's an interesting point @heybrother I'll bring that up to her next time we meet. It was a very brief visit to discuss basic procedural stuff, we didn't get into much detail about the rates compared to medicare.

 

[heybrother]

Brief bump.

-Joined an IPA.
-If all goes according to plan should be improving payment with a medium-major payor very favorably.
-There were a bunch of small plans in the area that I was never going to have the time to negotiate with / pursue. Most of them have been resolved very favorably.
-There's a bizarre fee schedule based on values from 20 something years ago but multiplied favorably. I will actually have to increase some fee schedules substantially to take advantage of it - however, its not a common insurance.
-The biggest take away though - the most common insurance in the state (ie. the most common best payor) pays little old me, an IPA elsewhere, and my IPA in town all the same. All of the orthos in town that aren't hospital employed are in the IPA. Obviously I'd like more money from them for their market place plan, but I'd say that's pretty fair that everyone gets paid the same. Yeah, all those orthos own surgery centers.
-Bummers though. My second worst commercial payor used to have a VERY favorable contract with the IPA. No more. 135/185%. Disappeared like 10 years ago. Another local payor that got bought out by a big in state entity also used to have a very favorable fee schedule. Sadly that contract is gone to. If those contracts were still in place joining the group would have solved all of my problems except United (who I will solve myself).

Now fun final thing.

I spoke to a private equity group. They want 20% of your profit forever. When you sell out you get cash in hand + shares and the shares have profit sharing from all sorts of the usual bull**** ventures ie. PCR labs, wound healing centers, vascular labs. They do pay less in EMR costs than I do by a lot. They claim to have better fee schedules.

Here's my problem.

It seems to me that their fee schedules can't be that much better than mine. The most common, best paying insurance in the state is paying little old me and 2 IPAs full of MDs the exact same. What are the odds they are paying a podiatry private equity group any better? This plan makes up probably 50+% of our revenue. Medicare makes up another substantial portion. As much as I would like to fix my other payors, they don't make up that much of our revenue compared to the above.

I think this is a trap to fall in. You join. You give up 20% of your profit. You think - "I'll make so much more money on each encounter so it'll be worth it". But you don't because the most common insurance pays everyone the same as does Medicare. You save some on EHR costs but you could have saved more by switching to something cheaper. In the end you are dependent on profit sharing from questionable ventures that are going to be targeted by Medicare. If your partner retires you'll still owe 20% of clinic profit but future hires won't get profit sharing from ventures ie. your new associate kicks in the 20% but doesn't receive profit sharing.

The only path forward is add new profitable services, control costs, ditch overpriced EHRs, negotiate when able, and then drop bad insurance. It isn't glamorous. Its slow. Its painful, but its the way.

 

[HardRoadPaved]

The most common, best paying insurance in the state is paying little old me and 2 IPAs full of MDs the exact same. What are the odds they are paying a podiatry private equity group any better?

Bingo. I saw my EOB when I saw a dermatologist. I made more than he does for a 99213. He better start billing level 4s for sending in a steroid cream Rx.