"it's so much harder to get reimbursed in primary care" - what does REALLY this mean?

[ramonaquimby]

i don't know why i'm so confused about this statement that i keep hearing over and over again. can someone give me a day-to-day example?

does this mean a patient comes in for a pap, i do a pap, and some crappy insurance company refuses to pay me for the pap? HUH?! and if so, is it because the ins company is claiming pt didn't need one / too young for one / too old for one? am i on the right track?


or does it mean a patient comes in for a pap, i do a pap, but some crappy insurance company refuses to pay me for the pap because i'm not an ob and i'm a primary care physician?

do tell. is it really THAT bad out there? eek!

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[edfig99]

it's something along the lines of your first example.

you provide a clinical service, and you submit a bill to get paid for that service. depending on the terms of your contract, you'll either get the amount you billed, or some portion thereof....or your claim gets denied for any number of reasons -- service not covered, too short a time period since that service was provided, further documentation needed, not credentialedto do that service, etc.

in addition to maybe getting paid something, the services provided in primary care are, for the most part, evaluation and management office visits (or preventive visits) which don't generate that much in income, say, compared to other procedural based specialties. for example, on one of the plans i am a member of, my most common "procedure" a level 3 office visit will reimburse at about $87 (actually, not me but the hospital i work for). in the time i do 10 or 15 of those, generating a whopping $870 to $1000, a surgeon will be able to get reimbursed about $3000 for a lap chole.

it's only as bad out there as the number and types of contracts you participate in.

 

[doc0875]

One recent example: Anthem BCBS in Ohio has recently started "blending" codes 99213/99214 & 99203/99204 (& payment for these). In other words, you can do all the associated & required work & documentation to qualify for the higher 99214 or 99204 reimbursement, but they will only pay you an amount somewhere in between the two codes (ie, less than the 99214 but more than the 9213). They are doing this because too many docs are now coding better, more appropriately, & higher because of EMR's, better coding education, etc. Anthem also requires that you automatically send notes before getting paid if you code a 99215 or 99205. This is just one example, there are many moe.

 

[doc0875]

"for example, on one of the plans i am a member of, my most common "procedure" a level 3 office visit will reimburse at about $87 (actually, not me but the hospital i work for)."


Where are you located that you get $87 for a level 3 outpatient visit? I do not get that for a 99214. Also, if your most common code is a 99213 then you are almost certainly undercoding (most doctors STILL do). You should have at least 50% 99214 visits if you have a fairly traditional patient base & document & code your work appropriately.

 

[deleted87716]

Anthem BCBS in Ohio has recently started "blending" codes 99213/99214 & 99203/99204 (& payment for these). In other words, you can do all the associated & required work & documentation to qualify for the higher 99214 or 99204 reimbursement, but they will only pay you an amount somewhere in between the two codes (ie, less than the 99214 but more than the 9213).

This is also being challenged, as it should be. See link.

Kevin, M.D. does a pretty good job summing up my own feelings on the issue.

 

[deleted87716]

i don't know why i'm so confused about this statement that i keep hearing over and over again. can someone give me a day-to-day example?

I'm not really sure. It's not necessarily any harder to get reimbursed in primary care compared to any other field, but the dollar amounts are generally smaller, and there are a lot more claims submitted simply because of the volume of patients we see. If you code and bill efficiently to minimize rejected claims, collect your co-payments in the office like you're supposed to, and manage your accounts receivable appropriately, you'll be fine. It's also essential to thoroughly evaluate the fee schedules of any insurance plans you intend to participate in. Many docs blindly sign up for plans that reimburse lower than Medicare. As long as there are docs dumb enough (or hungry enough) to do this, insurers will continue to ratchet down reimbursements. These issues are not limited to primary care; they affect all specialties.

 

[Echinoidea]

This may be a stupid question (I'm only an MSII considering a career in FP) but, if you bill Anthem say $100 for procedure XYZ, and they reimburse you $87, can't you just bill the patient for the remaining amount?

Or, is it possible to have a practice where you have the patients pay cash up front and then it's their responsibility to get reimbursed from the insurer?

 

[deleted87716]

This may be a stupid question (I'm only an MSII considering a career in FP) but, if you bill Anthem say $100 for procedure XYZ, and they reimburse you $87, can't you just bill the patient for the remaining amount?

Nope. When you sign a contract with an insurer, you agree to accept the insurer's fee schedule, and are prohibited from balance-billing patients for covered services. The exception is non-covered services. If a patient wants something that is not covered by their insurance company (e.g., a cosmetic procedure or an unusual screening test), you can bill the patient directly.

Or, is it possible to have a practice where you have the patients pay cash up front and then it's their responsibility to get reimbursed from the insurer?

Sure, you can do it. Just don't participate in any insurance plans. Good luck finding a lot of patients, however.

 

[deleted87716]

a patient comes in for a pap, i do a pap, and some crappy insurance company refuses to pay me for the pap? HUH?! and if so, is it because the ins company is claiming pt didn't need one / too young for one / too old for one? am i on the right track?

If you don't get paid for doing something like a Pap, there are several possibilities. First, your claim was coded incorrectly. Correcting and resubmitting the claim should result in payment (submitting a clean claim in the first place avoids this scenario). Second, the patient doesn't have insurance that pays for preventive services, such as a Pap smear (unlikely in this day and age, but possible). In this case, the cost of the Pap becomes the patient's responsibility, and they learn the importance of actually reading that fine print in their insurance contract. Finally, there's the possibility that their insurance plan will not pay for a routine Pap performed less than one year (to the day) after the last one. Again, if that's the case, it's the patient's problem...they get the bill, and they learn an expensive lesson in how their insurance plan works (which they should've known in the first place).

or does it mean a patient comes in for a pap, i do a pap, but some crappy insurance company refuses to pay me for the pap because i'm not an ob and i'm a primary care physician?

I'm not aware of any insurance plans that won't pay for primary care physicians to perform Pap smears. Generally, when you sign up to participate in an insurance plan, you receive a list of all of the CPT codes that they'll cover, along with their fee schedule. If you do something that's not included, you should ask about it. The only example that I can think of where this is an issue is with certain up-and-coming diagnostic tests, such as some of the newer cardiovascular risk markers (hs-CRP, homocysteine, VAP, etc.) Some insurers do not yet cover these tests, so I will usually have patients sign waivers when we order them, just as a reminder that they may have to pay for it.

Hope this helps!
Kent