Received an insurance fee schedule, it was much worse than expected! (is this normal?)

[geripsyched]

Hi, everyone! I'm transitioning to private practice and working on getting credentialed with a couple of the "good" insurances from my area. With one of the large insurance companies, it has been going very well. However, I just received a contract/fee schedule from another insurer. Here were their approximate rates for a level 5 new intake (99205):

Physician: ~$160
NP/PA: ~$190
MSW: slightly higher(?!) than the physician rate

Any idea what is going on? I know other psychiatrists get paid much higher rates from the same insurer (e.g., well over $200 for 99205). My area is extremely short on psychiatrists (most are affiliated with large mental health clinics that serve patients with SPMI and many of the community-based psychiatrists are retiring and struggling to find other providers to transition patients to). I would like to accept insurance so that I can see patients with a broader range of SES, but this experience surprised me. Have others experienced something like this? Is this part of the "negotiation" process?

Thanks! I always enjoy learning from your collective wisdom.

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[annoyedpsychiatrist]

Wait, am i reading this right? Why is that a NP would get more than you for the same code?

 

[Sushirolls]

Oh, yes. This is the reality. Sounds like this is Disjointed Death Care, or perhaps DigYuh (hole to nowhere financially) companies. Perhaps even EatYuh (just not at lunch, because you can't afford to buy food anymore) company.

 

[forchinet121]

99205?? 200? I don’t even know what to say that is too bad to even respond to you can’t operate a clinic with reimbursement like that..a new eval should be like 350 a 99214 is 150+ or else it’s not even worth it to be private practice

 

[geripsyched]

Oh, yes. This is the reality. Sounds like this is Disjointed Death Care, or perhaps DigYuh (hole to nowhere financially) companies. Perhaps even EatYuh (just not at lunch, because you can't afford to buy food anymore) company.

Too funny. I will never have anything to do with Disjointed Death Care (too many horror stories) but you may be onto something about DigYuh or EatYuh. ; )

 

[Sushirolls]

There is a chance that one company pays more for 90792 than 99205. Look at that. Double check the columns, see if there is a difference, perhaps that 99205 is for medicare/HMO rate? Or Mediciad? Or divided in location setting? Any possible error with first look impression?

I dropped Disjointed Death Care, but I know @randomdoc1 has insight into pushing for higher reimbursements, and deserves a bow for her efforts {her right?}.

In coming years I hope to eventually drop DigYuh and EatYuh.

In my area, Orange Religious Symbol keeps the lights on. All the other companies are so small in numbers doesn't really matter.

 

[geripsyched]

90972 is at least not as offensive, although NPs/PAs/psychologists still would be able to get noticeably more using the 99205 code. Here were the ballpark rates:

Physician/Psychologist: $160
NP/PA: $140
MSW: $120

We have a large insurer as well that dominates the area and has good rates (very similar to your experience). After this experience, I'll probably end up accepting traditional Medicare and that large insurer and then use cash payment (with superbills) for everyone else. I also sent the other insurance company some clarifying questions, including why are they valuing physician services less than others who have much less formal training. I don't expect a coherent, intelligible response (similar to when I call their call center). Oh, well! At least they were awful before I got too involved with them. It really sucks to get into a 3-year (length of contract) relationship, only to learn about their awfulness after the commitment has been made.

 

[Sushirolls]

You can be closed to new patients for that insurance. "or at capacity" or just schedule those patients once a month... What's the insurance cmpany going to do? Drop you?
I've not had any aspects of insurance contracts state X year enrollment, but usually 1 year duration with auto renewal. They will have clauses to drop each other over ~90 day periods. Look for those clauses in contract. And simply enact that now. Then send a message to whomever - which it will take a few days to find out whom and where - to say, these rates are abysmal, you have 1 week to correct this, or you will be dropped from my practice.

I did that with Disjointed Death Care, they responded by trying to up their rates with being on par with Medicare. At that point I was already disgruntled by all their other issues, that it really needed by double medicare for me to consider continuing with their hassles.

 

[ObsequiousAplomb]

Why would they list a psychologist being able to bill 90792? They can't. They bill 90791.

Also, why do they list an MSW as being able to do a 99205? They can't.

 

[geripsyched]

Thank you for your thoughtful replies, Sushirolls! My clinic hasn't opened yet, and I haven't signed a contract with this insurance company thankfully. I've recently received an email from this company saying that their rates are reviewed to be competitive relative to parameters driven by the market and industry. They also had some garbage about how their rates to different providers are proprietary - this behavior seems similar to how employers (illegally?) threaten their employees into not talking about their salaries with co-workers. Negotiating contracts is great when only one side has the info.

Soon I will send the insurance company an email telling them that their rates are not competitive and that I will cancel the intake appointments their patients already had scheduled for me later this summer (I've been receiving a lot of referrals from psychiatrists looking to retire/transition to other things).

ObsequiousAplomb - I wish I could upload the fee schedule they sent. You are right, in many ways it is nonsensical.

 

[clausewitz2]

Thank you for your thoughtful replies, Sushirolls! My clinic hasn't opened yet, and I haven't signed a contract with this insurance company thankfully. I've recently received an email from this company saying that their rates are reviewed to be competitive relative to parameters driven by the market and industry. They also had some garbage about how their rates to different providers are proprietary - this behavior seems similar to how employers (illegally?) threaten their employees into not talking about their salaries with co-workers. Negotiating contracts is great when only one side has the info.

Soon I will send the insurance company an email telling them that their rates are not competitive and that I will cancel the intake appointments their patients already had scheduled for me later this summer (I've been receiving a lot of referrals from psychiatrists looking to retire/transition to other things).

ObsequiousAplomb - I wish I could upload the fee schedule they sent. You are right, in many ways it is nonsensical.

While the relevant federal regulations do not apply to all workplaces, particularly small businesses that don't do any business with the government or take any government money for any reason, it is in fact illegal for employers to threaten, punish, or even tell employees that they're not allowed to discuss salary information. It is grounds for a complaint to the National Labor Relations Board, the agency that is meant to protect the collective bargaining process and provides the framework for unionization drives. They can investigate and impose substantial penalties on employers if they find evidence this is happening.

On the individual level, evidence that your employer was threatening you in violation of federal labor laws sounds like great ammunition in a wrongful termination suit or EEOC complaint in the future.

 

[calvnandhobbs68]

Why would they list a psychologist being able to bill 90792? They can't. They bill 90791.

Also, why do they list an MSW as being able to do a 99205? They can't.

That's what I was gonna say. It's literally not even legal for an MSW to bill an E+M code or 90792, so yeah the fee schedule doesn't make sense to begin with. You sure you reading this right OP?

 

[calvnandhobbs68]

99205?? 200? I don’t even know what to say that is too bad to even respond to you can’t operate a clinic with reimbursement like that..a new eval should be like 350 a 99214 is 150+ or else it’s not even worth it to be private practice

I get a little over $200 for a 99205 for most of my insurers, one actually even less but the followup rates are better so it evens out. None of my insurers pay $150 for a 99214. I will say that my fee schedule is not at all atypical for the area or the neighboring midwest state.

 

[forchinet121]

I get a little over $200 for a 99205 for most of my insurers, one actually even less but the followup rates are better so it evens out. None of my insurers pay $150 for a 99214. I will say that my fee schedule is not at all atypical for the area or the neighboring midwest state.

I agree it’s not atypical but it also sucks and you can make much more employed than doing that

 

[calvnandhobbs68]

I agree it’s not atypical but it also sucks and you can make much more employed than doing that

Maybe in a cash only private practice but even $200/hr x 7 patient hours/day x 48 weeks/yr is $336K/yr.

Saying this "sucks" is extremely regionally dependent.

 

[Sushirolls]

7 clinical hours per day, 5 days per week, for 48 working weeks if a rough schedule. But I'll run with those numbers:
$336,000 Gross

Supplies, EMR, insurance, lease, fax, phone, electric, internet, etc AND 1 FTE employee to do scheduling/billing, etc
-110K

Net is reduced to $226,000

Reduce 20% for SEP-IRA now net is, $180,800 [but 45K in retirement is nice!]

Reduce 22% in taxes. Maybe should do 24%? but we'll use 22%. We'll also assume getting health insurance from spouse. But I can change those number if one needs to pay for a family of 4 insurance. Let me know... Okay, 22% reduced, is now $141,024

Let's divide that by 12 to get a monthly idea. Which means, net in pocket is $11,752 for a very full time job.

I agree with @forchinet121 , that maybe the adjective suck is appropriate, when compared to employed opportunities.

For me, if that were the hourly rate I'd be netting from insurance, I'd strongly consider employed, or cash only.

It has been awhile since I've calculated, but $330-460/hr gross is where things are for my practice and that is viable.

 

[forchinet121]

Maybe in a cash only private practice but even $200/hr x 7 patient hours/day x 48 weeks/yr is $336K/yr.

Saying this "sucks" is extremely regionally dependent.

Compare it to the average employed job where you are making 65/wrvu on average you’ll come out far ahead in the hospital setting with that kind of reimbursement unfortunately

 

[comp1]

Come to the salaried side!

 

[calvnandhobbs68]

7 clinical hours per day, 5 days per week, for 48 working weeks if a rough schedule. But I'll run with those numbers:
$336,000 Gross

Supplies, EMR, insurance, lease, fax, phone, electric, internet, etc AND 1 FTE employee to do scheduling/billing, etc
-110K

Net is reduced to $226,000

Reduce 20% for SEP-IRA now net is, $180,800 [but 45K in retirement is nice!]

Reduce 22% in taxes. Maybe should do 24%? but we'll use 22%. We'll also assume getting health insurance from spouse. But I can change those number if one needs to pay for a family of 4 insurance. Let me know... Okay, 22% reduced, is now $141,024

Let's divide that by 12 to get a monthly idea. Which means, net in pocket is $11,752 for a very full time job.

I agree with @forchinet121 , that maybe the adjective suck is appropriate, when compared to employed opportunities.

For me, if that were the hourly rate I'd be netting from insurance, I'd strongly consider employed, or cash only.

It has been awhile since I've calculated, but $330-460/hr gross is where things are for my practice and that is viable.

Compare it to the average employed job where you are making 65/wrvu on average you’ll come out far ahead in the hospital setting with that kind of reimbursement unfortunately

I'm talking about take home fellas and I was being quite conservative with that net number. Gross is more around $300/hr at the rates I'm talking about up there if you're billing correctly and your panel is semi-full. Intakes are always going to be way less than followups on a per hour basis.

$65/wRVU is 1.92 x65 for a 99214 which is....$124.8. Which is the exact rate you said "sucked".

I agree that 160 is terrible for a 99205 but I'd also disagree that a new eval should "be like 350" in all settings. Like OP, most of the rates in this area are in the 200s for a 99205.

 

[Sushirolls]

wRVUs are relative. It's a metric to pay doctors...
It veils the total an employer gets when looking at total RVU for a service and all the different rates they collect when billing out.
Just another way to average out the payer mix to "simplify" paying docs for "productivity"

$65 per wRVU, using 99214 every 30min [$124.80], 7 hours per day, for 5 days per week and 48 weeks = 419K

Typically employed jobs, don't deduct most benefits from the wRVU conversion factor pay. So that is a straight 419K net, in context of a salaried job. If there are any deductions, less than 20K for the various things. $65 per wRVU has potential to be solid... not looking into the finer details and nooks and crannies of such a job.

 

[calvnandhobbs68]

wRVUs are relative. It's a metric to pay doctors...
It veils the total an employer gets when looking at total RVU for a service and all the different rates they collect when billing out.
Just another way to average out the payer mix to "simplify" paying docs for "productivity"

$65 per wRVU, using 99214 every 30min [$124.80], 7 hours per day, for 5 days per week and 48 weeks = 419K

Typically employed jobs, don't deduct most benefits from the wRVU conversion factor pay. So that is a straight 419K net, in context of a salaried job. If there are any deductions, less than 20K for the various things. $65 per wRVU has potential to be solid... not looking into the finer details and nooks and crannies of such a job.

You guys keep saying this but find me actual examples or postings of W2 jobs that pay 400K (with benefits on top of this) for doing 7 hour days. As again someone who within the last 2 years was looking in 2 different states for outpatient jobs, this is absolutely not the norm. Low to mid 300s is much more typical.

 

[KaiBuzz]

I think it’s worth paying a professional contract negotiator to support your initial contracting process. As you know, depending on your geographic location, Medicare pays ~$220-$260 for that code if you provide the service in an OP setting. I would start by asking the payers to increase the fee schedule to 100% of Medicare.

 

[Sushirolls]

That's because most jobs aren't 48 weeks of work. Nor are they 35 clinical hours per week. They are usually ~32 hrs per week give or take. Or 46 weeks per year of work.

Okay, just looked at a contract offer I had in hand from last summer. 32 hours clinical work, $55 wRVU, benefits fully covered in addition. 4 weeks vacation, 1 week CME. *unsure if sick days, didn't look that close. ~317K net for general adult outpatient work. On par with your description of low to mid 300's. The $60+ wRVU is out there though.

 

[allantois]

Clearly you need to hire an NP for better reimbursement lol

 

[forchinet121]

I'm talking about take home fellas and I was being quite conservative with that net number. Gross is more around $300/hr at the rates I'm talking about up there if you're billing correctly and your panel is semi-full. Intakes are always going to be way less than followups on a per hour basis.

$65/wRVU is 1.92 x65 for a 99214 which is....$124.8. Which is the exact rate you said "sucked".

I agree that 160 is terrible for a 99205 but I'd also disagree that a new eval should "be like 350" in all settings. Like OP, most of the rates in this area are in the 200s for a 99205.

65 dollars x 1.92 is 125 you are correct but what you’re mistaken with is that as employed doc this is your net income. As a PP this is gross so subtract (conservatively) 30 percent for overhead and you’re netting 87 dollars compared to 125 as employed..so yea this definitely sucks

 

[Mad Jack]

It seems to me like they're trying to keep the number of psychiatrists accepting their insurance low...

My other bet is that they put the rate that way because almost no NPs or PAs in the specialty use it for their new intakes so they've never had to adjust it. Physicians are usually seeing the complex stuff and bill accordingly. The fact that midlevels are paid less for a 90792 makes me inclined to believe this is the case.

Regardless, these reimbursement rates are shameful and unless someone is getting really good income on the follow-ups I can't see why they'd accept them

 

[clozareal]

I get a little over $200 for a 99205 for most of my insurers, one actually even less but the followup rates are better so it evens out. None of my insurers pay $150 for a 99214. I will say that my fee schedule is not at all atypical for the area or the neighboring midwest state.

I'm getting $200-350 for 99205s. For 99214s, insurance quoted me anywhere from $100-200 in my area, but most are in the $125 range.

 

[jbomba]

I'm getting $200-350 for 99205s. For 99214s, insurance quoted me anywhere from $100-200 in my area, but most are in the $125 range.

What's 90833 pay generally?

 

[Fpg1245]

I’m confused. Did you sign the contract before you knew what the rates were?

 

[clozareal]

What's 90833 pay generally?

For me, it was $40-100.

 

[ObsequiousAplomb]

For me, it was $40-100.

Crazy how wide that spread for 99214+90833 can be: $140-300. An afternoon being from $1100-2400. That variance really adds up.

 

[Sushirolls]

That variance is reflected in Payer Mix labels. I calculate, or had in the past, a blended payer mix.

1) look over a quarter how many 99214 and 99213 I billed out
2) make a spread sheet of the number of patients with each insurance, what that insurance pays for 99213 and 99214
3) smash all those numbers and percentages together to get a single number to assign to a 30min follow up as my own relative value unit per follow up visit. Gives a more defined hourly rate.

I hope to do this again after getting Q2 data.

@Fpg1245 Numerous insurance require people to sign before they divulge contracts and pay rate... Kind of pointless since they've passed no surprise billing acts and all this needs to be out there. I've seen some hospitals just post up the whole excel spreadsheet of every code and most every insurance they are paneled with. Informative way to do recon if you are every moving locations/states.

 

[jbomba]

Im currently talking to a medical biller who is recommending to go out of network with a variety of insurances..he's suggesting I'll get higher rates if I do it this way. Any thoughts?

 

[forchinet121]

Im currently talking to a medical biller who is recommending to go out of network with a variety of insurances..he's suggesting I'll get higher rates if I do it this way. Any thoughts?

Isn’t out of network just mean you don’t take their insurance?

 

[jbomba]

Isn’t out of network just mean you don’t take their insurance?

As it was explained to me, not quite..you are an out of network provider they have an agreement with. You aren't listed as one of their providers but if a pt comes to you you submit your billing to them and they'll reimburse.

 

[clozareal]

As it was explained to me, not quite..you are an out of network provider they have an agreement with. You aren't listed as one of their providers but if a pt comes to you you submit your billing to them and they'll reimburse.

They'll reimburse you or the patient? I don't know if this is right. Why would insurance want to do this? If you have an agreement with them, then you are either in network or have a single case agreement with them. I am out of network with many insurances when patients submit a superbill and insurances have often asked me to send them a W-9 or fill out an out of network provider info form so they can reimburse the right person (not me usually, but they have sent the check to my previous employers before)

 

[jbomba]

They'll reimburse you or the patient? I don't know if this is right. Why would insurance want to do this? If you have an agreement with them, then you are either in network or have a single case agreement with them. I am out of network with many insurances when patients submit a superbill and insurances have often asked me to send them a W-9 or fill out an out of network provider info form so they can reimburse the right person (not me usually, but they have sent the check to my previous employers before)

I asked about this and was told a superbill is different. I'll update as I get further info on this.

 

[splik]

As it was explained to me, not quite..you are an out of network provider they have an agreement with. You aren't listed as one of their providers but if a pt comes to you you submit your billing to them and they'll reimburse.

No. out of network means you are not contracted with insurance. It's basically being cash only. Most out of network docs (such as myself) provide superbills for their patients. However, you can submit the claims to insurance on behalf of your patients as a courtesy.That's pretty common in other fields. However, I'm not sure why you want to do that. then you have the same headaches you would if you accepted insurance. What if they take a year to pay? (which Anthem BCBS is notorious for), write off the charges?, reimburse 0 for them [which frequently happens to my pts]?, want to audit you, request money back etc? You also then have to figure out how much the patient owes you etc.

For example, your fee is $300 for 99214+90833 but the patients OON benefits are 60% and the maximum allowed amount is hypothetically $90 for 99214 and $80 for 90833. That means the insurance will pay out $102 and the patient is on the hook for the rest. Sometimes the insurance companies will ask you to accept a lower amount (often insultingly low) to receive quicker payment. This is Optum/UHC's schtick through multiplan.

There are also single case agreements where you are in network just for a particular patient and they might pay your full fee (they will usually try to get you to agree to a lower amount). Then there are network gap exceptions (also called network deficiencies) where the insurance company agrees to reimburse as if in network at the maximum allowed amount (which could be less than your full rate if it's very high). In that case you can submit the claims to insurance for patients but then you're screwed if they don't pay out anything. Best to have patients deal with all that stuff and know they are ultimately on the hook for the cost of your visits.

 

[Sushirolls]

^^^^ @splik nailed it.

I've submitted in past erronesously a few claims to insurance I wasn't in network with.... Then on the EOB statement, it says stuff like we pay $100 out of your $300 bill and has all over that "patient not responsible for remainder." Uh, no, we are not in network you can't say that. But that has now been introduced into the 3 way communications of billing.

Keep it simple, only bill to insurance you are in network with. All others are up to the patient.