Opting out of medicare?

[JewOnThis]

This is a question for those in private practice.

I have been considering about opting out of medicare. It just seems like there are way too many rules and regulations with Medicare and our clinic will just function as well without it.


Is there anyone out there that has a successfully ran clinic without taking medicare?

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[dtrack22]

This is a question for those in private practice.

I have been considering about opting out of medicare. It just seems like there are way too many rules and regulations with Medicare and our clinic will just function as well without it.


Is there anyone out there that has a successfully ran clinic without taking medicare?

What issues are you having with Medicare? What % of Medicare is your fee schedule with BCBS, Aetna, Cigna, UHC, etc?

Lots of docs don't take Medicare. Probably not a lot of podiatrists given the coverage of your average nail patient...

We take it but Medicare only makes up maybe 15-20% of the patients I see. BCBS is a bigger pain in the arse than Medicare IMO. We just happen to have a decent contract with them (about 120% of Medicare) so the $ makes it worth it. If I was one of those suckers accepting a Blue Cross contract with a fee schedule that is less than 100% of Medicare then I would drop them before I would drop Medicare. Wouldn't even think twice.

 

[Carbon13]

One thing I like about Medicare is that the deductible is low & most people have secondary coverage. Therefore, we don't have to perform a tutorial class on insurance payment when each patient gets to the checkout window. Heck, sometimes that's worth the decreased fee schedule compared to BC.BS

 

[dtrack22]

One thing I like about Medicare is that the deductible is low & most people have secondary coverage. Therefore, we don't have to perform a tutorial class on insurance payment when each patient gets to the checkout window. Heck, sometimes that's worth the decreased fee schedule compared to BC.BS

I’ve found this to be true too.

Medicare can also be nice when it comes to getting paid on claims. Put in the correct codes and modifiers and you get paid no questions asked. Don’t do anything shady and you have nothing to worry about. BCBS (Anthem) now has their computer system set up to auto-reject any claim with a 25 modifier. You know how many extra man hours that takes to get paid on those claims? UHC won’t pay for multiple matrixectomies. Not just a reduced fee for the second procedure...$0.

I don’t want the feds more involved in any aspect of my life but compared to most commercial plans they probably are less of a headache for me.

 

[Scrantonicity]

I’ve found this to be true too.

Medicare can also be nice when it comes to getting paid on claims. Put in the correct codes and modifiers and you get paid no questions asked. Don’t do anything shady and you have nothing to worry about. BCBS (Anthem) now has their computer system set up to auto-reject any claim with a 25 modifier. You know how many extra man hours that takes to get paid on those claims? UHC won’t pay for multiple matrixectomies. Not just a reduced fee for the second procedure...$0.

I don’t want the feds more involved in any aspect of my life but compared to most commercial plans they probably are less of a headache for me.

No questions asked, unless it's Humana Medicare lol....geez those guys ask for charts like there's no tomorrow...

 

[dtrack22]

Humana Medicare lol

Humana is one worth opting out of. The best is their semi-annual denial of all claims. Like once every 6 months they pick a CPT code and just don’t pay it until you appeal it once or three times with your visit notes. I’m positive they do it just because they know a handful of docs won’t appeal it and they’ll save some money.

 

[ExperiencedDPM]

Humana is one worth opting out of. The best is their semi-annual denial of all claims. Like once every 6 months they pick a CPT code and just don’t pay it until you appeal it once or three times with your visit notes. I’m positive they do it just because they know a handful of docs won’t appeal it and they’ll save some money.

It’s not always a conspiracy to steal your money. I am not defending any particular company, but as someone who’s been a consultant for many years, there’s more to the story. Each insurer has their own reason for asking for charts. It may be that they are adjusting their pay rate. It may be that you are billing codes at a higher rate than your peers. It may be that the profession as a whole is billing a procedure more often than expected. It may be totally random. And many other reasons.

I can tell you that some insurers are automatically reviewing Podiatric claims for 28725-subtalar arthrodesis and 28585–open reduction with internal fixation of a talo-tarsal dislocation. Why have they picked these codes?? It’s because of past abuse by our profession. DPMs are constantly billing these codes for performing an ARTHROEREISIS, which is simply fraud. You can rationalize all you want, but placing a metallic stent or object in the sinus tarsi is NOT a subtalar arthrodesis or ORIF of a talk tarsal dislocation. But it’s billed that way by our peers daily.

So the chart review may be for many reasons, including random or caused by some of our greedy peers.

 

[dtrack22]

It’s not always a conspiracy to steal your money. I am not defending any particular company, but as someone who’s been a consultant for many years, there’s more to the story. Each insurer has their own reason for asking for charts. It may be that they are adjusting their pay rate. It may be that you are billing codes at a higher rate than your peers. It may be that the profession as a whole is billing a procedure more often than expected. It may be totally random. And many other reasons.

I agree. Humana just seems, on the surface, more sinister than the rest of them. Mostly because their reason for the denial is some procedure not being a covered benefit due to the LCD. And every single time that's 100% incorrect. And every time we get paid after submitting an appeal. And then every time for 6-8 months you will get paid for the same code on their patients and then they start rejecting them all again for the same reason...that is still 100% incorrect. It really feels like its being done on purpose when they reject something they know is covered all along.

So the chart review may be for many reasons, including random or caused by some of our greedy peers.

This seems to be the reason for a lot of the headache and hoops we all have to jump through when it comes to getting reimbursed as podiatrists...

 

[Scrantonicity]

Humana is one worth opting out of. The best is their semi-annual denial of all claims. Like once every 6 months they pick a CPT code and just don’t pay it until you appeal it once or three times with your visit notes. I’m positive they do it just because they know a handful of docs won’t appeal it and they’ll save some money.

So true. I wish it wasn't such a big one in my area, or I would opt out. In the meantime, I guess I just keep sending them my charts and have them find new things they want me to tweak (which totally contradict the last things they told me to tweak). It's a fun game haha