Is medicare reimbursement the best?

[trixter888]

Just talked with the biller for the company I am working for. I am in the process of getting credentialed with the all the insurance companies, but have not yet. She informed me that medicare reimburses the highest and that I should expect all other insurance providers to fall in between medicare and medicaid rates.

This is so surprising to me given that Medicare reimburses us $204 for a 90792 and $173 for a 99204.

Can anyone confirm this?

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[Sushirolls]

Other SDN posters in other parts of the country have stated that's the case.

I'm in a geographic pocket where 2 companies, high percentage of market, are less than medicare. One recently was willing to bump up to +/- same as medicare. The other company I dropped from my panel. All the rest of mine are in excess of medicare.

 

[WisNeuro]

I have a couple that are higher. There's one substantially below that most people avoid. One thing about Medicare, it can be a beast to do all of teh credentialing paperwork and such for a business, but they are probably the most straightforward in terms of billing and getting paid.

 

[trixter888]

Other SDN posters in other parts of the country have stated that's the case.

I'm in a geographic pocket where 2 companies, high percentage of market, are less than medicare. One recently was willing to bump up to +/- same as medicare. The other company I dropped from my panel. All the rest of mine are in excess of medicare.

Very interesting. From the internet, I found that private insurances exceed medicare rates. I am just trying to figure out if trying to start a cash practice (higher or equal rates to medicare) makes financial sense.

Thank you!

 

[jbomba]

This is a stupid question I'm sure, but if I were to take Medicare does that mean strictly a geri population?

 

[Sushirolls]

Nope. Depends up on your area. Geriatrics for sure but there may be a large population of younger folks who are on disability for various reasons, and with SSD often comes Medicare insurance.

 

[TexasPhysician]

Rates vary significantly by zip code even. 99204 is always > 90792 in my area. I’ve seen colleagues in my city have rates all under and all over Medicare. It just depends.

 

[clausewitz2]

Careful with starting a cash practice with the idea of accepting medicate patients, at least if it is a side gig at first. If you work anywhere else for another employer and take Medicare there in any capacity, it would be illegal for you to accept cash to see patients with medicare in your private practice.

 

[dl2dp2]

Careful with starting a cash practice with the idea of accepting medicate patients, at least if it is a side gig at first. If you work anywhere else for another employer and take Medicare there in any capacity, it would be illegal for you to accept cash to see patients with medicare in your private practice.

Yes, just add on to that -- practicing with insurance vs. cash are very different. In order to achieve max reimbursement, the idea is to "see" as many people as often as possible and fulfill the requirements in documentation using a checkbox approach, if you are accepting insurance, and always bill at the top of the code. In a cash practice, the priority is to make the customer happy and deliver service that is of the highest value to the patient given the time you have. Medicare is all in or all out. If you want to accept cash for Medicare patients you need to be opted out of Medicare altogether.

 

[trixter888]

Just curious, what do are the average cash rates for private practice. I have heard of a huge range of numbers.

 

[NickNaylor]

Just curious, what do are the average cash rates for private practice. I have heard of a huge range of numbers.

You've probably heard a wide range of numbers because it will vary widely even within the same area. In the Dallas area, which is where I am, the hourly rate ranges anywhere from $200/hr to $600/hr. I'm sure there are some psychiatrists in bigger cities that charge even more because the market is big enough to sustain those rates.

 

[trixter888]

You've probably heard a wide range of numbers because it will vary widely even within the same area. In the Dallas area, which is where I am, the hourly rate ranges anywhere from $200/hr to $600/hr. I'm sure there are some psychiatrists in bigger cities that charge even more because the market is big enough to sustain those rates.

Thank you! There are no cash practice psychiatrists in my area. From googling people, going on their websites there doesn't seem to be a predominant cash pay only option. I wonder if it is because the market cannot bear it. I am however in a million plus person city. I am trying to figure out if starting to take cash makes sense!

 

[splik]

Careful with starting a cash practice with the idea of accepting medicate patients, at least if it is a side gig at first. If you work anywhere else for another employer and take Medicare there in any capacity, it would be illegal for you to accept cash to see patients with medicare in your private practice.

I will mention one exception as this is a common source of confusion. The above only applies to original medicare beneficiaries. If the patient has medicare advantage it is as if they don't have medicare at all for cash only practices and you can charge them what you like (assuming you don't have an agreement with whatever plan they put their medicare into).

 

[clausewitz2]

I will mention one exception as this is a common source of confusion. The above only applies to original medicare beneficiaries. If the patient has medicare advantage it is as if they don't have medicare at all for cash only practices and you can charge them what you like (assuming you don't have an agreement with whatever plan they put their medicare into).

Did not know that about Medicare advantage, that is genuinely helpful.

 

[Sushirolls]

Indeed.

I did learn that if you opt out of Medicare you can't accept these medicare advantage patients, another random kernel.

 

[clozareal]

In my area for Medicare, a 99214+90833 = $240 which is about a 30-45 minute appointment, coming out to $320-480/hr. New evaluations are reimbursed lower if you take 60 minutes, but still $232/hr (for 90792) or $264 (for 99205) in my MAC locality which is HCOL. It's about $20 extra in 2021 compared to 2020 per each follow-up E&M code.

PFS Look-up Tool Overview | CMS

The PFS Look-Up Tool gives Medicare payment information on more than 10,000 services, including pricing, associated relative value units, and payment policies.

www.cms.gov

One of the billing companies I'm looking at says that BCBS IL is the only higher paying insurance company than Medicare.

 

[reca]

I'm confused, why do so many psychiatrists opt out of Medicare then? $480/hour is higher than most cash pay psychiatrists in my area ($300/hour).

 

[Sushirolls]

Geriatric patients, not all, but a big chunk take more time. Cognitive decline, and coordinating with family, or dispos to higher level care or support is all stuff that takes time. You do it, or an office staff member must do it. Longer med lists, longer health lists, longer active medical comorbidities. Then as we barrel into the technology era with Telemedicine and bureaucratic forms and push for electronic everything - many geriatrics are not compatible with technology. So this requires more office staff time.

On the other side of the coin are younger patients who have disability for XYZ, and are now on Medicare. These patients often times need other services like eating disorders, SUDs inpatient, or therapists, etc - of which so few take. So there you are with a high acuity patient who can't ever get connected to the resources and you are stuck with a high risk patient who will also call often, schedule often, etc and just not make much progress.

Then medicare has more rules. More requirements of annual fraud training BS stuff for you and your staff. No thanks. I'm done with mandatory training stuff, and trying to cut out bureaucracy where I can. Then with medicare comes all the advantage plans, the HMO plans(!!!!!), or supplemental plans. Of which you will learn you are in network with some but not the others. And has a whole 'nother layer of billing headaches - which either means more staff - or more unpaid visits. I used a 3rd party biller in the past (don't recommend) and they only go so far to get real answers, and real resolution. Your own staff then gets tied up with numerous 30-45min phone calls with insurance, which should be assumed the default per needed call to insurance....

At some point the reality sets in, you can't do and be everything for everyone. You don't get tax breaks like the Big Box shop non-profit behmouths. You don't get the better paying insurance rates the Big Box shops do. So the question is, to stay viable, to keep your office doors open, nay, to keep your practice viable for you to want to continue doing it to not have to close up and go back to work for Big Box Shop, you need to draw the line in the sand some where for unit of effort to money pocketed. Each person/practice will have a different threshold.

I still have one foot in the door with medicare - not taking new patients - out of fear if I needed to revert back to a Big Box shop job for some reason. I'm hoping to drop medicare by the end of this year. This is the last vestige remaining for me being truly 100% into private practice. The reason why its an issue for any doctor, is Medicare has a ridiculous rule that they won't let you back in until after 2 years have lapsed from your dropping medicare. Go figure.


That graph looks quite different in my metro.
Most insurance greater than medicare, and below that are 2 insurance behemoths, and then medicaid.

 

[FlowRate]

I'm confused, why do so many psychiatrists opt out of Medicare then? $480/hour is higher than most cash pay psychiatrists in my area ($300/hour).

Some people enjoy/prefer to offer integrated/combined treatment (meds+therapy). To actually do therapy, you need more than 30 minutes. That brings your rate down to whatever 99214+90834/7 reimburses in your region. And with the added time sink (cost) of insurance paperwork.

 

[nexus73]

Medicare reimbursements are regional. In my location, I'm told (but don't see these numbers personally because I'm selling soul to the bix box shop), has psychiatrists opting out or not taking any Medicare because the pay is actually less than the state Medicaid. Even masters level therapists don't take Medicare, but do take Medicaid. So get paid the least to take on the most involved patients....it's a no brainer here.

 

[splik]

In my area for Medicare, a 99214+90833 = $240 which is about a 30-45 minute appointment, coming out to $320-480/hr. New evaluations are reimbursed lower if you take 60 minutes, but still $232/hr (for 90792) or $264 (for 99205) in my MAC locality which is HCOL. It's about $20 extra in 2021 compared to 2020 per each follow-up E&M code.

PFS Look-up Tool Overview | CMS

The PFS Look-Up Tool gives Medicare payment information on more than 10,000 services, including pricing, associated relative value units, and payment policies.

www.cms.gov

One of the billing companies I'm looking at says that BCBS IL is the only higher paying insurance company than Medicare.

View attachment 342790

Silicon Valley is the only area you would approach that reimbursement for 99214+90833 there’s a GPCI factor that básically accounts for the cost of doing business geographically. In that part of the country that would be less than the cash only price for psychiatry.

also this graph is garbage I wouldn’t use any billing company who is suggesting that this is the case. They may be incentivized to encourage Medicare as you are more likely to use a biller in that cases vs doing it yourself if you accept select insurances

 

[splik]

Pros of accepting Medicare
They are a reliable payer
They pay their bills quickly
They pay reasonable for follow up visits
They are very clear about what their requirements are in terms of documentation etc
The fee schedule is available online so you know what to expect from the get go
It allows you to see patients with disabilities and seniors who may not be able to afford your care otherwise
They will pay for multiple times per week psychotherapy (either E&M + psychotherapy or psychotherapy standalone), including psychoanalysis

Cons of accepting Medicare
Mess up and they feds will come after you
Errors in billings can lead to criminal as well as civil penalties
They claw back money they may have paid you
You may have to participate in MACRA/MIPS
They are the only payer that the reimbursement almost reliably decreases year on year (there was an increase for outpatient E&M and standalone psychotherapy codes this yr, but that will go down next yr)
Medicare only pays 80% of the bill. If the patient has a supplemental plan you don't accept, or has medicaid as secondary then it will cause you problems as the patient may not be expecting to be on the hook for the remainder, and if they have medicaid, you can't charge them the 20% that medicare won't pay for.

 

[Sushirolls]

Corrections:
They are my slowest payer, takes forever, and I'm paneled with 7+. May just be my local MAC I'm under.
There fee schedule once you get a ERA/EOB is not clear like the listed rates they publish. The deductions for sequestration, took me months to fully analyze and understand how to read their EOBs. They are the most complex of all insurance companies.


MIPS alone is reason enough to to avoid them.
Medicare is oriented towards geriatric, so they don't cover things like vistaril/hydroxzine (need a PA!!) but they will oddly cover a benzo. So when you are working with the younger population, and trying to not prescribe benzos, their lack of coverage for hydroxyzine is mind boggling. I get why its there, but that emphasis on the primary population of geriatrics makes it difficult and more burdensome for us.

 

[clausewitz2]

also this graph is garbage I wouldn’t use any billing company who is suggesting that this is the case. They may be incentivized to encourage Medicare as you are more likely to use a biller in that cases vs doing it yourself if you accept select insurances

Yeah, was about to say, the two big insurance plans in my neck of the woods reliably pay 10-15% more than Medicare.

 

[liquidshadow22]

If you take Medicare, can you pick and choose which patients you actually take on?

 

[splik]

If you take Medicare, can you pick and choose which patients you actually take on?

You can always pick and choose which patients you take on, for whatever reason, just keep that reason to yourself.

 

[liquidshadow22]

You can always pick and choose which patients you take on, for whatever reason, just keep that reason to yourself.

There are a lot telepsych practices that essentially screen out SMI, PD, and high self harm risk patients.

I do telepsych only and Medicare definitely reimburses much better than the other commercial insurances in my locality, wondering if I should bite the bullet and take Medicare but just have very strict criteria for who I take on.

Can you elaborate on the exact differences btw billing Medicare vs commercial insurance and why it's a headache?

 

[calvnandhobbs68]

There are a lot telepsych practices that essentially screen out SMI, PD, and high self harm risk patients.

I do telepsych only and Medicare definitely reimburses much better than the other commercial insurances in my locality, wondering if I should bite the bullet and take Medicare but just have very strict criteria for who I take on.

Can you elaborate on the exact differences btw billing Medicare vs commercial insurance and why it's a headache?

splik gives great reasons a few posts up. Along with sushi.

Medicare has a lot of rules and regulations that come along with it. It tends to be a slow payer. You’re subject to a lot of regulations surrounding government insurance (same with Medicaid) that isn’t a problem with private insurance (ex anti-kickback rules really only apply to government insurance, so you have to be really careful about your relationship with referral sources), MIPS, etc. Medicare is really pushing “quality” metrics while most private insurances are quite happy to just pay FFS. there’s all kinds of rules about what you can and can’t bill patients for that they can complain to the government about (ex no show fees).

For solo/small practices it hardly seems worth it to have a large number of your patients as Medicare patients.

 

[liquidshadow22]

splik gives great reasons a few posts up. Along with sushi.

Medicare has a lot of rules and regulations that come along with it. It tends to be a slow payer. You’re subject to a lot of regulations surrounding government insurance (same with Medicaid) that isn’t a problem with private insurance (ex anti-kickback rules really only apply to government insurance, so you have to be really careful about your relationship with referral sources), MIPS, etc. Medicare is really pushing “quality” metrics while most private insurances are quite happy to just pay FFS. there’s all kinds of rules about what you can and can’t bill patients for that they can complain to the government about (ex no show fees).

For solo/small practices it hardly seems worth it to have a large number of your patients as Medicare patients.

Optum, cigna pay absolute dogcrap.BCBS and Aetna are reasonable. I don't know how you grow an insurance based practice without Medicare which pays close to double optum and cigna in my locality.

 

[calvnandhobbs68]

Optum, cigna pay absolute dogcrap.BCBS and Aetna are reasonable. I don't know how you grow an insurance based practice without Medicare which pays close to double optum and cigna in my locality.

UBH is one of my better payers actually. Cigna pays similar to Aetna in my locale, both less than Optum but not terrible, although it would definitely affect my bottom line if I had mostly Cigna/Aetna patients (about 10-11% less). BCBS pays similar to UBH for me, less for news but about the same for followups. Medicare wouldn't be too much more than Optum or BCBS in my market.

Again, private insurance is super super regional and controlled by regional market/insurance districts. So some people say UBH reimbursement is terrible, some people feel its okay.

 

[Merovinge]

Medicare is oriented towards geriatric, so they don't cover things like vistaril/hydroxzine (need a PA!!) but they will oddly cover a benzo. So when you are working with the younger population, and trying to not prescribe benzos, their lack of coverage for hydroxyzine is mind boggling. I get why its there, but that emphasis on the primary population of geriatrics makes it difficult and more burdensome for us.

Ah yes, the dreaded anticholinergics clearly are a bridge too far but load em up on chronic daily benzos. Glad reasonable pharmacists and psychiatrists are determining their approved medications.

 

[deleted1100659]

IMO it's a complicated question. It depends on your health and what doctors you often visit. For example, I've got dental issues and found a perfect advantage plan ( core info on Medigap vs. Medicare Advantage) which includes useful free extras and covers spending on appointments and some prescription medicine

He meant more of what insurances are reimbursing the most to physicians for office visits