How a doctor makes money?

[Postictal Raiden]

@group_theory

I'm currently doing an outpatient rotation. My preceptor sees nearly only Medicaid patients. High volume though. He seems to be doing well financially, and he admitted it to me when I asked.

However, I have a hard time reconciling that with what I found out about the reimbursement rates for Medicaid (my state is one of the worst when it comes to Medicaid-to-Medicare ratio in terms of reimbursements. ~40% of what Medicare pays!). For example, a high complexity new patient visit (99204) reimburses only ~$80 while a f/u visit is only $40!

I'm wondering if there's more to the story than this. Could it be that the middle man company (HMO) that this doctor contracts with pays higher rates than what the plane medicaid rate is?

Thanks

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[Scrubb]

@group_theory

I'm currently doing an outpatient rotation. My preceptor sees nearly only Medicaid patients. High volume though. He seems to be doing well financially, and he admitted it to me when I asked.

However, I have a hard time reconciling that with what I found out about the reimbursement rates for Medicaid (my state is one of the worst when it comes to Medicaid-to-Medicare ratio in terms of reimbursements. ~40% of what Medicare pays!). For example, a high complexity new patient visit (99204) reimburses only ~$80 while a f/u visit is only $40!

I'm wondering if there's more to the story than this. Could it be that the middle man company (HMO) that this doctor contracts with pays higher rates than what the plane medicaid rate is?

Thanks

Yes, contracted managed Medicaid (e.g. Medicaid HMO) plans sometimes do pay higher rates than straight Medicaid.

A lot of it depends on how the state has their Medicaid program set up and the specific contract in question. Sometimes it will be a percent, for example 110% of the state Medicaid fee schedule. Or sometimes it will be a negotiated fee schedule that isn’t explicitly based off the state Medicaid fee schedule. These rates can definitely be higher than what straight Medicaid would pay. But again, depends on the state’s setup and provider contract.

Source: have worked in hospital reimbursement consulting

 

[VA Hopeful Dr]

Yes, contracted managed Medicaid (e.g. Medicaid HMO) plans sometimes do pay higher rates than straight Medicaid.

A lot of it depends on how the state has their Medicaid program set up and the specific contract in question. Sometimes it will be a percent, for example 110% of the state Medicaid fee schedule. Or sometimes it will be a negotiated fee schedule that isn’t explicitly based off the state Medicaid fee schedule. These rates can definitely be higher than what straight Medicaid would pay. But again, depends on the state’s setup and provider contract.

Source: have worked in hospital reimbursement consulting

The volume could be part of it as well. In my area, a regular f/u visit with regular insurance pays around $110. So 3 medicaid f/u's in that same time would actually pay $10 more.

 

[Postictal Raiden]

The volume could be part of it as well. In my area, a regular f/u visit with regular insurance pays around $110. So 3 medicaid f/u's in that same time would actually pay $10 more.

In which part of the country do you practice ?

 

[VA Hopeful Dr]

In which part of the country do you practice ?

Southeast

 

[Postictal Raiden]

Southeast

Thank you.

Seems that the SE and the West are terrible with Medicaid reimbursements.

 

[Bacchus]

@group_theory

I'm currently doing an outpatient rotation. My preceptor sees nearly only Medicaid patients. High volume though. He seems to be doing well financially, and he admitted it to me when I asked.

However, I have a hard time reconciling that with what I found out about the reimbursement rates for Medicaid (my state is one of the worst when it comes to Medicaid-to-Medicare ratio in terms of reimbursements. ~40% of what Medicare pays!). For example, a high complexity new patient visit (99204) reimburses only ~$80 while a f/u visit is only $40!

I'm wondering if there's more to the story than this. Could it be that the middle man company (HMO) that this doctor contracts with pays higher rates than what the plane medicaid rate is?

Thanks

Just a thought and I don't know if this is true/makes sense/etc.

If this preceptor works in a health system, there is a wRVU rate. So, regardless of what you bring in, you will be paid the standard rate (at least at my institution). Ultimately, with a large number of health practices in a network, the income "works out."

Our residency clinic attendings get reimbursed much less than what my office does (a high proportion of medicaid VS only 10% at my office). However, comparing the two offices, if everyone was paid as an employed physician it would be based on their wRVUs.

 

[Postictal Raiden]

Just a thought and I don't know if this is true/makes sense/etc.

If this preceptor works in a health system, there is a wRVU rate. So, regardless of what you bring in, you will be paid the standard rate (at least at my institution). Ultimately, with a large number of health practices in a network, the income "works out."

Our residency clinic attendings get reimbursed much less than what my office does (a high proportion of medicaid VS only 10% at my office). However, comparing the two offices, if everyone was paid as an employed physician it would be based on their wRVUs.

He's a solo practitioner. Basically he eats what he kills.

About 70% of his patients is made of medicaid, 20% medicare, and the rest is a mix of private insurance and self-pay. Despite this terrible payor mix, he claims he makes well above MGMA figures. I guess it's the volume.

 

[Bacchus]

He's a solo practitioner. Basically he eats what he kills.

About 70% of his patients is made of medicaid, 20% medicare, and the rest is a mix of private insurance and self-pay. Despite this terrible payor mix, he claims he makes well above MGMA figures. I guess it's the volume.

How many patients a day?

 

[Postictal Raiden]

How many patients a day?

40-50

 

[Bacchus]

40-50

There’s the answer. Very hard to provide quality care with that many patients...in family medicine.

 

[Postictal Raiden]

There’s the answer. Very hard to provide quality care with that many patients...in family medicine.

What do you think is the max at which quality of care starts to get compromised?