- Joined
- Oct 17, 2011
- Messages
- 3,072
- Reaction score
- 7,001
Hopefully this will be more amusing than talking about nailcare.
1. Be wary of making long term decisions based on short term financial incentives.
2. A private practice essentially requires all of its members to work at full steam. A podiatrist is either collecting or you are carrying them.
3. Collections are important - but controlling costs is a millimeter behind. A lean office doesn't need a fortune in collections.
4. Toxic partners can make you physically ill. They create a myriad staffing and patient care issues.
5. What you will tolerate as a new graduating podiatrist and what you will tolerate as an established, skilled podiatrist should not be the same thing.
6. Be wary of problematic partnerships rooted in financial convenience. Partnership borders on a marriage.
7. Old podiatrists do not change.
8. Staff will ghost you. The kind of people who will work in a podiatry office are often poor, high school-at-most educated, women. When I see their paychecks I don't know how they survive. They make $10-20 an hour. They could probably make more money at McDonalds. They'll leave you for $2 more an hour, better lifestyle or not having to clean your exam rooms at the end of the day. Your staff will share their salaries with each other and they will begrudge other employees who make more money if that employee doesn't pull their weight. They know how hard they've worked at other offices or how little at better staffed offices. They know that some other doctor gives $$$ upfront to every employee for their 401k or that the general surgery office has a stocked break room for their employees. They know the family medicine doctor treats all of his employees and their family for free. They'll leave the office because it changed its paycheck structure from 24 to 26 pay periods and it threw off their budget. They are interviewing and looking for something better even though they are showing up every day. Send someone home early to control costs because their doctor wasn't in the office and you blew their budget and they can't make their rent payment. They'll look for a new job. Staff will tell you on Friday they aren't coming Monday. Training a replacement? Putting in 2 weeks? Probably not. Medical assistants don't have to build a resume of quality work. The kind of people who hire them are just like you - looking for someone to start on a Monday because someone else just ghosted them. They don't share in the profits of the office so their only incentive is money and occasionally a feeling of loyalty to their doctor. They don't think they should have to wait a year to get a $0.50 raise - they can get a raise by moving to a new office on Monday that pays more if they can find it. They don't believe in seniority or that people who have been there longer should earn more money. Everyone's doing the same job and they've been an MA for 5-10-15 years somewhere else. They will cut the best deal they can get.
*I actually think most of my practice's staffing issues are self inflicted, but I've seen some funny stuff. I can't blame MA who are often living hand to mouth for cutting a better deal. If we could all walk away and start something better that next Monday - we would.
9. The amount of money lost by losing a motivated employee greatly exceeds whatever trivial amount of money you lost them over.
10. My stereotypical boomer dad would say - "this whole generation doesn't want to work. They think they deserve too much money." Describing entire generations with a broad brush is dumb. I'm 41 and therefore technically a millenial. The relationship between management and labor has changed. Transparency works against management. Evolve or die.
11. Old practices have legacy costs that are difficult to break or escape. Personal friendships may have influenced business decisions.
12. Old practices can have lingering financial concerns that are difficult to root out like overcollections that haven't been repaid. Don't ask me how I know this.
13. You cannot truly change a practice unless you own a controlling stake in it.
14. Health insurance continues to explode in price. A major health insurance company can raise your practice's office plan rates 8% in a year and simultaneously cut your practice's reimbursement by greater than that. If your employee is a young, single mother with children it is entirely possible that her family can receive a subsidy that will cover the entirety of the premium of a marketplan plan. When Obamacare was passed one of the concerns was that employers would be motivated to drop their employees onto the market place. The financial incentive to do this can actually be substantial. If you were paying $500 a month for an employee's health insurance the savings to the practice would be $6000 and the employee could potentially be covered entirely by subsidy with no cost to themself. *I don't know this but I suspect in certain states your employee could also be placed onto Medicaid which might or might be well received (income, children dependent etc). If the employee is older or has a working spouse of moderate means - you could also be creating a situation where they could owe a substantial component of their premium. When I evaluated the finances of discontinuing my practices health insurance I found that an employee in their 60s would likely owe at least $300 a month because they had a spouse who made $50-60K. We (the practice) would be saving substantial employee premiums, but likely causing a tremendous financial burden for this employee because older employees cost more to insure and family's with more income receive less premium subsidy (especially if they don't have dependents). Market place plans can often have co-pays that employees would have difficulty to afford - for example, $100+ specialist copays.
15. This forum spends a lot of time discussing associate contracts, but very little time discussing partner contracts. Partner contracts are dramatically more complicated. Make no assumption. You may think you are buying out a podiatrist who is supposed to be retiring - and you may desire to leave before they do.
16. For whatever reason it is very difficult to teach management type employees to understand how insurance works. I have had plural conversations with "educated" individuals who believe that increasing the prices of your fee schedule will increase reimbursement from insurance companies. This is true under a very, very, very limited number of circumstances. The vast majority of your reimbursement will be determined by a fixed value in an insurance fee schedule. You can set your practice's fee schedule to $1,000,000 for a 99203. It will not increase your reimbursement.
17. I wrote a post about insurance years this years ago but I'll hit the highpoints again with a new weird thing
-Get your fee schedules from each insurance company and understand them. Find the variations. Create a master table of your most common codes for every insurance. Insurance companies will sign a contract with you and then underpay you on the contract. You'll be sitting there rendering the service believing you've got a great rate only to find out it never materialized (if you aren't looking you won't catch it) and it takes forever for them to reprocess. Knowing your fee schedules backwards and forwards allows you to catch these issues, spot the outliers etc. Get your contracts. The time to find out what you are paid is not after you've rendered the service.
-Most insurance plans reimburse some variation of the Medicare fee schedule but it may not be current year. Most insurance companies did not take the 2021 E&M update into account. Medicare in my area routinely reimburses E&M higher than almost all major commercial insurance companies. A recent increase in one of my fee schedules for CPT codes was accompanied by no change at all in E&M values which remained moderately sub-Medicare even thought the CPT codes are solidly positive over Medicare.
-There is no correlation between how private practice (collections) and how hospital podiatrists (RVUs) are reimbursed and brooding on it won't make you a penny.
-A "good" insurance plan elsewhere may be a trash plan in your area. In the state of North Carolina it appears Aetna has a transparent Medicare positive reimbursement that is posted freely online (like 165% of Medicare). Meanwhile in Texas, Aetna is now my second worst payor (soon to be worst) and reimburses all codes sub-Medicare. They also routinely deny all 25 modifier follow-up encounters now matter the appropriateness.
-Insurance companies can set your prices however they choose without any basis. They can reimburse 20550 and 20551 $30 apart. They can reimburse percutaneous flexor tenotomies higher than open tenotomies even though the Medicare fee schedule values are the reverse. They can reimburse a 17110, 11042 at $50 if they want to even though that is less than 50% of Medicare and 17110 has a 10 day global. They do not have to be consistent. Its whatever the schedule says.
-On some fee schedules a 20550 can be worth more than a 99213 and on others the reverse. Will that influence how you deliver care?
-I have literally seen a fee schedule where podiatry-centric codes were devalued - where codes around them were specified as based on Medicare x % and podiatry-centric codes were annotated as reduced due to policy.
-Insurance can specify that they will reimburse the lesser of (Medicare x %) or (Fee schedule - 20%). If you set your fee schedule values at the former, you'll lose 20% to the latter.
-Historically there was a variation of something called a "Silent PPO". A patient presents with an insurance company card (usually some sort of small 3rd party company you've never heard of) that doesn't specify the network. When the charges are submitted, the insurance company would submit the charges to a "discounter" who would reduce your fee schedule based on the lowest contractual rate you had with any network. Theoretically, your reduction in fee schedule is based on an insurance contract where the insurance gives you patients and you give them a discount. Since this insurance and discounter have no relationship with you there is no reason for them to deserve a discount. Some states have outlawed this, but there are still slight "variants" of this. What essentially happens now is a patients present with an insurance that sends claims to a discounter you've never heard of that treats all claims as "In network but subject to their fee schedule". For example, patients were presenting to my office with an insurance card listing both a company I'd never heard of and "ClaimDOC" - a company in Des Moines. This is actually slightly transparent as I've also received insurance cards with no company or network name on them anywhere. I initially contacted the insurance company on the card asking for their fee schedule only to finally be directed to ClaimDoc who told me they are "open network" and reimburse all claims at 125% of Medicare. They told me this over the phone ie. I'm not sharing some sort of contractual secret. There is no reason for me to offer these patients a discount. I am not in network with ClaimDOC. A similar company was "Sana" who literally have to coach their patrons to tell the doctor's office "don't worry - we're "open network" and the claims will be taken care of". In my area, most physician offfices figured out that "open network" means garbage reimbursement and refused to see their patients. It seems that ultimately Sana added the Healthsmart network because no one would see their patients.
*What's the lesson to learn here - tell patients with insurance cards (a) that have no network (b) or have a network you've never heard of that you are out of network and they need to pay cash they won't be seen. The second you submit to these companies they reduce your fee schedule and there isn't much you can do. An out of network provider who declares / informs the patient of this ahead of time should be able to balance bill a patient - but that isn't happening here because of how the claims are being processed.
-Its been discussed previously, but its entirely possible that if you accept some garbage payor - you may be the only doctor in an area seeing them. I recently confronted "FirstHealth" about their garbage fee schedules. It turns out in my area that FirstHealth is owned by Aetna and that no one accepts it. This is essentially legacy baggage as a result of being in an established practice. Maybe back in the day FirstHealth was a real insurance that paid something. Maybe it never did, but whatever the process the practice signed up for it. We do not see a lot of patients with this insurance, but going forward we will be seeing zero.
18. At times it very much feels like you can't possibly afford enough employees to deal with insurance company shenanigans. Reviewing my practices "held" claims I do find problematic submissions (not mine), but I also find claims that are simply denied because the insurance company can. For example, a Medicare Advantage plan claiming that the kenalog in a patient's plantar fascial injection is not covered by the plan. A plan refusing to pay 28113 unless you submit a letter of medical necessity.
19. Small insurance companies that reimburse at high values often will process their claims so slowly that unless you capture a substantial deposit up front it becomes hard to get patients to pay their balance.
20. Patients do not seem to care anymore about being sent to collections. The credit score law change has taken all of the bite out of the process. Calling patients after the fact and asking them to pay their bill has a very low yield with every minute that passes from the date of the service.
21. I'm sometimes told that its a good idea to be in a wealthy area. I won't discount the value of this, but patient wealth doesn't increase what Medicare pays to an office. If you are offering self-pay services like shockwave or laser then perhaps there will be people who can afford it. However, a multi-millionaire with Medicare will still be worth Medicare's fee schedule if all you bill is covered service. Perhaps wealthy people are more likely to pay their claims or pay for uncovered service, but "utility" or "federal" employees with Cadillac BCBS plans seem to be what keeps my practice in business.
22. A devil's advocate argument against higher paying commercial insurance (where the patient may owe the bill) is that Medicare patients with a secondary require almost no effort to be dedicated to collections because their plans + secondary pays the entire claim even if it is not excellent reimbursement. There is a start of the year deductible and some patients will claim that they "never had to pay this before". In my office, a Medicare 99203 + 73630 etc beats out a dramatic number of commercial insurances. It doesn't beat BCBS or Cigna most of the time, but it beats most of the other large payors. You'll sometimes read online that "doctors offices receive more money from commercial insurance than Medicare". Your mileage may vary on this, but that's not the case for me.
23. I sometimes hear stories about difficulties that doctors offices have with insurance. I've heard stories in the past of patients not being allowed to have nail surgery without prior authorization. I have not experienced that ie. most things in the office don't seem to require any sort of effort (other than collecting payment). MRIs and CTs do often require a "peer to peer" for commercial insurance, but I often am able to bypass the physician by simply telling the review nurse why I'm ordering it. The "denials" are often for trivial things like "didn't perform x-ray" - even though we did. Anthem BCBS seems to always require IM and HV angle measurements to authorize bunion surgery. Anything done with United should jokingly be prior authorized twice because they'll deny it after the fact in a heartbeat and claim you didn't prior authorize it. Securing payment after the fact is probably issue #1. HMO plan patients showing up without a referral is issue #2. Established HMO patients don't seem to understand that their referral runs out. They believe their referral lasts forever and it doesn't. Trivial, but getting bone stimulators covered is a nuisance.
24. I'm currently out of network with 2 area Medicare Advantage plans with a new one dropping soon. My experience billing MA plans out of network is that you ultimately receive Medicare level reimbursement, but the patients owes a higher co-pay. I will be out of network with United very soon and I'm curious to see how they'll process the claims. Your mileage may vary, but if your office is receiving sub-Medicare reimbursement from MA plans then going out of network may address some of the underpayment issues albeit at greater expense to the patient. There was a person on Iped recently claiming that a MA plan was going to pay them 120% of Medicare, but another doctor's office sabotaged the agreement by agreeing to a lower rate. I would love to see that exchange.
25. No insurance that I've dropped has ever asked me to stay or offered to negotiate.
26. No insurance that has ever negotiated has offered more than 10% over what they offered to begin with.
27. I recently got United Healthcare to agree that they had not paid me at my contractually indicated rate - for like 2-3 years. They ultimately sent me an enormous excel of underpaid claims which was full of non-sense data and inappropriately calculated. Its only a partial portion of the data. I immediately knew they were trying to underpay me because I had performed rough calculations of my total United collections and knew a ballpark of what the claims were worth. I contacted their rep and said the values were non-sense - there was never a question in our prior discussions of what I was owed but suddenly they want me to agree to settlement in 10 days on non-sense before a vacation. The rep refused to ask their team to reprocess the claims unless I commented on every single line what was wrong with the process. I was then forced to manually pull Medicare fee schedule data into excel, create a vlookup table in excel and provide the actual Medicare fee schedule values for the entire table along with the underpayment value. I also manually went through my EHR counts and codes to try and determine if the data included all of the claims I should have been paid for. It didn't. After spending hours doing this, United then agreed that they'd pulled the table wrong and ultimately they did it right the second time and my reimbursement doubled. I had a certain skillset from a prior career that allowed me to disassemble their data, but this is the kind of thing that will kill your spirit in private practice. No one my practice has ever employed could have done what I did. The check I'll be receiving is for thousands of dollars. Hospital employed podiatrists are not doing crap like this. The time, effort, cost of managing a podiatry practice is substantial and essentially uncompensated.
28. I occasionally hear people discussing "famous podiatrists" who demand cash up front. The question often asked is - "why can't I demand $2000 for a bunion up front". The answer is - your insurance contract. If you want to charge patients your fee schedule price - go out of network.
29. Do everything you can to avoid practice expenses that take a set percentage of your collections. Your expenses should ideally be as close to fixed as possible so that increasing revenue results in increasing keep. I would strongly recommend against Athena though I acknowledge many billers appear to have a %-of collections approach.
30. Its very easy for a practice to only be "forward looking". See the patients. Solve their problems. Book the surgeries. Do the work and move on - there's always someone to work on, something new to be doing, a note to be written. Insurance companies often process and deny claims so slowly that its hard to look back and say - did we get paid for that? You could literally have a long follow-up with a patient over months and still not have their surgical claim processed during that time. The best time to take money from a patient is either (a) before you do the surgery (b) or while they are still coming to your office. Once they are discharged and not following up its like squeezing water from a rock.
31. If all of your surgical reimbursement is Medicare or less - you are probably wasting your time. A substantial portion of your surgeries need to pay at 2-2.6+ x Medicare to be an actual revenue contributor to your practice unless you personally own shares in the surgery center or receive some sort of distribution.
32. A newly started practice may be well positioned to control costs because there are no legacy costs that are simply being paid without consideration. It is very hard to leave an EHR, even if its overpriced. Everything can be questioned. That said, the "grandfathered" nature of the insurance system can potentially create situations where an old practice down the street is better reimbursed than a new practice. IPAs can be helpful, but their benefit is sometimes mixed. None of the most problematic (low) payors (United, Aetna) had contracts with any of the IPAs I spoke to.
33. We speak about the devalued nature of the work we perform, but in the end the primary basis for our rates is Medicare. It is for most practices a substantial payor, the basis of commercial insurance reimbursement, and in many cases declining in value yearly.
34. Since I like to have it both ways. Depending on your payor mix, it sometimes feels like we live in a world that is worse than Medicare for all. If you see a strong mix of sub-Medicare payors - Humana, Aetna, United, Blue Cross "marketplace" etc - you are literally living in a sub-Medicare world where you also still have to collect your balances from the patients, get referrals, perform prior authorization. I obviously I have no idea what a true Medicare only world would feel be like but one of my motivations for dropping certain payors is that simply anything would better than them.
35. No one has ever asked me what board I am certified by.
36. Cash pay services are interesting. I added shockwave by purchasing a used device. I've actually had very positive outcomes. The simple truth though is that the backbone of revenue remains higher reimbursing commercial insurance. If you gave me the choice of offering people shockwave or simply having more good commercial nail surgery walk through the door - I'd take nail surgery. You don't have to sell it to patients. The vast majority of infected or painful nails are agreeable to doing something definitive.
1. Be wary of making long term decisions based on short term financial incentives.
2. A private practice essentially requires all of its members to work at full steam. A podiatrist is either collecting or you are carrying them.
3. Collections are important - but controlling costs is a millimeter behind. A lean office doesn't need a fortune in collections.
4. Toxic partners can make you physically ill. They create a myriad staffing and patient care issues.
5. What you will tolerate as a new graduating podiatrist and what you will tolerate as an established, skilled podiatrist should not be the same thing.
6. Be wary of problematic partnerships rooted in financial convenience. Partnership borders on a marriage.
7. Old podiatrists do not change.
8. Staff will ghost you. The kind of people who will work in a podiatry office are often poor, high school-at-most educated, women. When I see their paychecks I don't know how they survive. They make $10-20 an hour. They could probably make more money at McDonalds. They'll leave you for $2 more an hour, better lifestyle or not having to clean your exam rooms at the end of the day. Your staff will share their salaries with each other and they will begrudge other employees who make more money if that employee doesn't pull their weight. They know how hard they've worked at other offices or how little at better staffed offices. They know that some other doctor gives $$$ upfront to every employee for their 401k or that the general surgery office has a stocked break room for their employees. They know the family medicine doctor treats all of his employees and their family for free. They'll leave the office because it changed its paycheck structure from 24 to 26 pay periods and it threw off their budget. They are interviewing and looking for something better even though they are showing up every day. Send someone home early to control costs because their doctor wasn't in the office and you blew their budget and they can't make their rent payment. They'll look for a new job. Staff will tell you on Friday they aren't coming Monday. Training a replacement? Putting in 2 weeks? Probably not. Medical assistants don't have to build a resume of quality work. The kind of people who hire them are just like you - looking for someone to start on a Monday because someone else just ghosted them. They don't share in the profits of the office so their only incentive is money and occasionally a feeling of loyalty to their doctor. They don't think they should have to wait a year to get a $0.50 raise - they can get a raise by moving to a new office on Monday that pays more if they can find it. They don't believe in seniority or that people who have been there longer should earn more money. Everyone's doing the same job and they've been an MA for 5-10-15 years somewhere else. They will cut the best deal they can get.
*I actually think most of my practice's staffing issues are self inflicted, but I've seen some funny stuff. I can't blame MA who are often living hand to mouth for cutting a better deal. If we could all walk away and start something better that next Monday - we would.
9. The amount of money lost by losing a motivated employee greatly exceeds whatever trivial amount of money you lost them over.
10. My stereotypical boomer dad would say - "this whole generation doesn't want to work. They think they deserve too much money." Describing entire generations with a broad brush is dumb. I'm 41 and therefore technically a millenial. The relationship between management and labor has changed. Transparency works against management. Evolve or die.
11. Old practices have legacy costs that are difficult to break or escape. Personal friendships may have influenced business decisions.
12. Old practices can have lingering financial concerns that are difficult to root out like overcollections that haven't been repaid. Don't ask me how I know this.
13. You cannot truly change a practice unless you own a controlling stake in it.
14. Health insurance continues to explode in price. A major health insurance company can raise your practice's office plan rates 8% in a year and simultaneously cut your practice's reimbursement by greater than that. If your employee is a young, single mother with children it is entirely possible that her family can receive a subsidy that will cover the entirety of the premium of a marketplan plan. When Obamacare was passed one of the concerns was that employers would be motivated to drop their employees onto the market place. The financial incentive to do this can actually be substantial. If you were paying $500 a month for an employee's health insurance the savings to the practice would be $6000 and the employee could potentially be covered entirely by subsidy with no cost to themself. *I don't know this but I suspect in certain states your employee could also be placed onto Medicaid which might or might be well received (income, children dependent etc). If the employee is older or has a working spouse of moderate means - you could also be creating a situation where they could owe a substantial component of their premium. When I evaluated the finances of discontinuing my practices health insurance I found that an employee in their 60s would likely owe at least $300 a month because they had a spouse who made $50-60K. We (the practice) would be saving substantial employee premiums, but likely causing a tremendous financial burden for this employee because older employees cost more to insure and family's with more income receive less premium subsidy (especially if they don't have dependents). Market place plans can often have co-pays that employees would have difficulty to afford - for example, $100+ specialist copays.
15. This forum spends a lot of time discussing associate contracts, but very little time discussing partner contracts. Partner contracts are dramatically more complicated. Make no assumption. You may think you are buying out a podiatrist who is supposed to be retiring - and you may desire to leave before they do.
16. For whatever reason it is very difficult to teach management type employees to understand how insurance works. I have had plural conversations with "educated" individuals who believe that increasing the prices of your fee schedule will increase reimbursement from insurance companies. This is true under a very, very, very limited number of circumstances. The vast majority of your reimbursement will be determined by a fixed value in an insurance fee schedule. You can set your practice's fee schedule to $1,000,000 for a 99203. It will not increase your reimbursement.
17. I wrote a post about insurance years this years ago but I'll hit the highpoints again with a new weird thing
-Get your fee schedules from each insurance company and understand them. Find the variations. Create a master table of your most common codes for every insurance. Insurance companies will sign a contract with you and then underpay you on the contract. You'll be sitting there rendering the service believing you've got a great rate only to find out it never materialized (if you aren't looking you won't catch it) and it takes forever for them to reprocess. Knowing your fee schedules backwards and forwards allows you to catch these issues, spot the outliers etc. Get your contracts. The time to find out what you are paid is not after you've rendered the service.
-Most insurance plans reimburse some variation of the Medicare fee schedule but it may not be current year. Most insurance companies did not take the 2021 E&M update into account. Medicare in my area routinely reimburses E&M higher than almost all major commercial insurance companies. A recent increase in one of my fee schedules for CPT codes was accompanied by no change at all in E&M values which remained moderately sub-Medicare even thought the CPT codes are solidly positive over Medicare.
-There is no correlation between how private practice (collections) and how hospital podiatrists (RVUs) are reimbursed and brooding on it won't make you a penny.
-A "good" insurance plan elsewhere may be a trash plan in your area. In the state of North Carolina it appears Aetna has a transparent Medicare positive reimbursement that is posted freely online (like 165% of Medicare). Meanwhile in Texas, Aetna is now my second worst payor (soon to be worst) and reimburses all codes sub-Medicare. They also routinely deny all 25 modifier follow-up encounters now matter the appropriateness.
-Insurance companies can set your prices however they choose without any basis. They can reimburse 20550 and 20551 $30 apart. They can reimburse percutaneous flexor tenotomies higher than open tenotomies even though the Medicare fee schedule values are the reverse. They can reimburse a 17110, 11042 at $50 if they want to even though that is less than 50% of Medicare and 17110 has a 10 day global. They do not have to be consistent. Its whatever the schedule says.
-On some fee schedules a 20550 can be worth more than a 99213 and on others the reverse. Will that influence how you deliver care?
-I have literally seen a fee schedule where podiatry-centric codes were devalued - where codes around them were specified as based on Medicare x % and podiatry-centric codes were annotated as reduced due to policy.
-Insurance can specify that they will reimburse the lesser of (Medicare x %) or (Fee schedule - 20%). If you set your fee schedule values at the former, you'll lose 20% to the latter.
-Historically there was a variation of something called a "Silent PPO". A patient presents with an insurance company card (usually some sort of small 3rd party company you've never heard of) that doesn't specify the network. When the charges are submitted, the insurance company would submit the charges to a "discounter" who would reduce your fee schedule based on the lowest contractual rate you had with any network. Theoretically, your reduction in fee schedule is based on an insurance contract where the insurance gives you patients and you give them a discount. Since this insurance and discounter have no relationship with you there is no reason for them to deserve a discount. Some states have outlawed this, but there are still slight "variants" of this. What essentially happens now is a patients present with an insurance that sends claims to a discounter you've never heard of that treats all claims as "In network but subject to their fee schedule". For example, patients were presenting to my office with an insurance card listing both a company I'd never heard of and "ClaimDOC" - a company in Des Moines. This is actually slightly transparent as I've also received insurance cards with no company or network name on them anywhere. I initially contacted the insurance company on the card asking for their fee schedule only to finally be directed to ClaimDoc who told me they are "open network" and reimburse all claims at 125% of Medicare. They told me this over the phone ie. I'm not sharing some sort of contractual secret. There is no reason for me to offer these patients a discount. I am not in network with ClaimDOC. A similar company was "Sana" who literally have to coach their patrons to tell the doctor's office "don't worry - we're "open network" and the claims will be taken care of". In my area, most physician offfices figured out that "open network" means garbage reimbursement and refused to see their patients. It seems that ultimately Sana added the Healthsmart network because no one would see their patients.
*What's the lesson to learn here - tell patients with insurance cards (a) that have no network (b) or have a network you've never heard of that you are out of network and they need to pay cash they won't be seen. The second you submit to these companies they reduce your fee schedule and there isn't much you can do. An out of network provider who declares / informs the patient of this ahead of time should be able to balance bill a patient - but that isn't happening here because of how the claims are being processed.
-Its been discussed previously, but its entirely possible that if you accept some garbage payor - you may be the only doctor in an area seeing them. I recently confronted "FirstHealth" about their garbage fee schedules. It turns out in my area that FirstHealth is owned by Aetna and that no one accepts it. This is essentially legacy baggage as a result of being in an established practice. Maybe back in the day FirstHealth was a real insurance that paid something. Maybe it never did, but whatever the process the practice signed up for it. We do not see a lot of patients with this insurance, but going forward we will be seeing zero.
18. At times it very much feels like you can't possibly afford enough employees to deal with insurance company shenanigans. Reviewing my practices "held" claims I do find problematic submissions (not mine), but I also find claims that are simply denied because the insurance company can. For example, a Medicare Advantage plan claiming that the kenalog in a patient's plantar fascial injection is not covered by the plan. A plan refusing to pay 28113 unless you submit a letter of medical necessity.
19. Small insurance companies that reimburse at high values often will process their claims so slowly that unless you capture a substantial deposit up front it becomes hard to get patients to pay their balance.
20. Patients do not seem to care anymore about being sent to collections. The credit score law change has taken all of the bite out of the process. Calling patients after the fact and asking them to pay their bill has a very low yield with every minute that passes from the date of the service.
21. I'm sometimes told that its a good idea to be in a wealthy area. I won't discount the value of this, but patient wealth doesn't increase what Medicare pays to an office. If you are offering self-pay services like shockwave or laser then perhaps there will be people who can afford it. However, a multi-millionaire with Medicare will still be worth Medicare's fee schedule if all you bill is covered service. Perhaps wealthy people are more likely to pay their claims or pay for uncovered service, but "utility" or "federal" employees with Cadillac BCBS plans seem to be what keeps my practice in business.
22. A devil's advocate argument against higher paying commercial insurance (where the patient may owe the bill) is that Medicare patients with a secondary require almost no effort to be dedicated to collections because their plans + secondary pays the entire claim even if it is not excellent reimbursement. There is a start of the year deductible and some patients will claim that they "never had to pay this before". In my office, a Medicare 99203 + 73630 etc beats out a dramatic number of commercial insurances. It doesn't beat BCBS or Cigna most of the time, but it beats most of the other large payors. You'll sometimes read online that "doctors offices receive more money from commercial insurance than Medicare". Your mileage may vary on this, but that's not the case for me.
23. I sometimes hear stories about difficulties that doctors offices have with insurance. I've heard stories in the past of patients not being allowed to have nail surgery without prior authorization. I have not experienced that ie. most things in the office don't seem to require any sort of effort (other than collecting payment). MRIs and CTs do often require a "peer to peer" for commercial insurance, but I often am able to bypass the physician by simply telling the review nurse why I'm ordering it. The "denials" are often for trivial things like "didn't perform x-ray" - even though we did. Anthem BCBS seems to always require IM and HV angle measurements to authorize bunion surgery. Anything done with United should jokingly be prior authorized twice because they'll deny it after the fact in a heartbeat and claim you didn't prior authorize it. Securing payment after the fact is probably issue #1. HMO plan patients showing up without a referral is issue #2. Established HMO patients don't seem to understand that their referral runs out. They believe their referral lasts forever and it doesn't. Trivial, but getting bone stimulators covered is a nuisance.
24. I'm currently out of network with 2 area Medicare Advantage plans with a new one dropping soon. My experience billing MA plans out of network is that you ultimately receive Medicare level reimbursement, but the patients owes a higher co-pay. I will be out of network with United very soon and I'm curious to see how they'll process the claims. Your mileage may vary, but if your office is receiving sub-Medicare reimbursement from MA plans then going out of network may address some of the underpayment issues albeit at greater expense to the patient. There was a person on Iped recently claiming that a MA plan was going to pay them 120% of Medicare, but another doctor's office sabotaged the agreement by agreeing to a lower rate. I would love to see that exchange.
25. No insurance that I've dropped has ever asked me to stay or offered to negotiate.
26. No insurance that has ever negotiated has offered more than 10% over what they offered to begin with.
27. I recently got United Healthcare to agree that they had not paid me at my contractually indicated rate - for like 2-3 years. They ultimately sent me an enormous excel of underpaid claims which was full of non-sense data and inappropriately calculated. Its only a partial portion of the data. I immediately knew they were trying to underpay me because I had performed rough calculations of my total United collections and knew a ballpark of what the claims were worth. I contacted their rep and said the values were non-sense - there was never a question in our prior discussions of what I was owed but suddenly they want me to agree to settlement in 10 days on non-sense before a vacation. The rep refused to ask their team to reprocess the claims unless I commented on every single line what was wrong with the process. I was then forced to manually pull Medicare fee schedule data into excel, create a vlookup table in excel and provide the actual Medicare fee schedule values for the entire table along with the underpayment value. I also manually went through my EHR counts and codes to try and determine if the data included all of the claims I should have been paid for. It didn't. After spending hours doing this, United then agreed that they'd pulled the table wrong and ultimately they did it right the second time and my reimbursement doubled. I had a certain skillset from a prior career that allowed me to disassemble their data, but this is the kind of thing that will kill your spirit in private practice. No one my practice has ever employed could have done what I did. The check I'll be receiving is for thousands of dollars. Hospital employed podiatrists are not doing crap like this. The time, effort, cost of managing a podiatry practice is substantial and essentially uncompensated.
28. I occasionally hear people discussing "famous podiatrists" who demand cash up front. The question often asked is - "why can't I demand $2000 for a bunion up front". The answer is - your insurance contract. If you want to charge patients your fee schedule price - go out of network.
29. Do everything you can to avoid practice expenses that take a set percentage of your collections. Your expenses should ideally be as close to fixed as possible so that increasing revenue results in increasing keep. I would strongly recommend against Athena though I acknowledge many billers appear to have a %-of collections approach.
30. Its very easy for a practice to only be "forward looking". See the patients. Solve their problems. Book the surgeries. Do the work and move on - there's always someone to work on, something new to be doing, a note to be written. Insurance companies often process and deny claims so slowly that its hard to look back and say - did we get paid for that? You could literally have a long follow-up with a patient over months and still not have their surgical claim processed during that time. The best time to take money from a patient is either (a) before you do the surgery (b) or while they are still coming to your office. Once they are discharged and not following up its like squeezing water from a rock.
31. If all of your surgical reimbursement is Medicare or less - you are probably wasting your time. A substantial portion of your surgeries need to pay at 2-2.6+ x Medicare to be an actual revenue contributor to your practice unless you personally own shares in the surgery center or receive some sort of distribution.
32. A newly started practice may be well positioned to control costs because there are no legacy costs that are simply being paid without consideration. It is very hard to leave an EHR, even if its overpriced. Everything can be questioned. That said, the "grandfathered" nature of the insurance system can potentially create situations where an old practice down the street is better reimbursed than a new practice. IPAs can be helpful, but their benefit is sometimes mixed. None of the most problematic (low) payors (United, Aetna) had contracts with any of the IPAs I spoke to.
33. We speak about the devalued nature of the work we perform, but in the end the primary basis for our rates is Medicare. It is for most practices a substantial payor, the basis of commercial insurance reimbursement, and in many cases declining in value yearly.
34. Since I like to have it both ways. Depending on your payor mix, it sometimes feels like we live in a world that is worse than Medicare for all. If you see a strong mix of sub-Medicare payors - Humana, Aetna, United, Blue Cross "marketplace" etc - you are literally living in a sub-Medicare world where you also still have to collect your balances from the patients, get referrals, perform prior authorization. I obviously I have no idea what a true Medicare only world would feel be like but one of my motivations for dropping certain payors is that simply anything would better than them.
35. No one has ever asked me what board I am certified by.
36. Cash pay services are interesting. I added shockwave by purchasing a used device. I've actually had very positive outcomes. The simple truth though is that the backbone of revenue remains higher reimbursing commercial insurance. If you gave me the choice of offering people shockwave or simply having more good commercial nail surgery walk through the door - I'd take nail surgery. You don't have to sell it to patients. The vast majority of infected or painful nails are agreeable to doing something definitive.
