Starting new practice- a few questions

[Eyefixer]

Hello friends,

I am opening a practice as of July first. A couple of questions:

1. I don't want to buy an A-scan right of the bet and getting an IOL Master is quite expensive at first. What are the options for getting IOL calc in this situation? Send them to ASC or local ophthalmologists for these tests? Any other suggestions?

2. Billing . What's an acceptable rate for an outside billing company? I heard everything from 6 to 10% of collections.

3. Maybe this is a silly question, but what do people do before you get all the provider #? See pts for free? As far as I know you can only retrobill Medicare? Any info on that?

Thanks a lot.

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[KHE]

Hello friends,

I am opening a practice as of July first. A couple of questions:

1. I don't want to buy an A-scan right of the bet and getting an IOL Master is quite expensive at first. What are the options for getting IOL calc in this situation? Send them to ASC or local ophthalmologists for these tests? Any other suggestions?

2. Billing . What's an acceptable rate for an outside billing company? I heard everything from 6 to 10% of collections.

3. Maybe this is a silly question, but what do people do before you get all the provider #? See pts for free? As far as I know you can only retrobill Medicare? Any info on that?

Thanks a lot.

I can not speak to issue #1:

2: In the early stages, don't farm out your billing. Do it yourself, or hire a staff person who is competent enough to do it. In the early goings of a practice, you are NOT going to want 6-10% flying out the door right off the bat.

3: You should definately enroll in whatever managed care programs you want to BEFORE you open your practice. That process can often times be time consuming and frustrating. If you are opening on July 1st and have not started becoming credentialled, start NOW!

 

[Eyefixer]

You should definately enroll in whatever managed care programs you want to BEFORE you open your practice. That process can often times be time consuming and frustrating. If you are opening on July 1st and have not started becoming credentialled, start NOW!

Thanks for advice. I am on the way with Medicare and Medical (I am in CA); although both applications were sent back to me yesterday for corrections (and it's not the first time; how frustrating!). Private insurances can be applied for not earlier than 1 month prior to residency end point. I am not planning to take managed care.

 

[KHE]

Thanks for advice. I am on the way with Medicare and Medical (I am in CA); although both applications were sent back to me yesterday for corrections (and it's not the first time; how frustrating!). Private insurances can be applied for not earlier than 1 month prior to residency end point. I am not planning to take managed care.

If you are only going to be accepting medicare and medical as third party payors, then I'm not sure I understood your questions correctly. When you say you aren't signing up for any managed care, what are you referring to? HMOs? Capitated plans?

Also, what rule is there that states that private insurance can not be signed up for for one month prior to residency end point? Who's policy is that?

 

[Eyefixer]

If you are only going to be accepting medicare and medical as third party payors, then I'm not sure I understood your questions correctly. When you say you aren't signing up for any managed care, what are you referring to? HMOs? Capitated plans?

I am not currently planning on signing on with HMO/Managed care plans. I am in the process of signing up with Medicare/Medical, which is a painful and long process.

Also, what rule is there that states that private insurance can not be signed up for for one month prior to residency end point? Who's policy is that

It seems to the a rule for most private insurance companies; ex. BS of CA, Healthnet, Aetna, etc.

 

[KHE]

I am not currently planning on signing on with HMO/Managed care plans. I am in the process of signing up with Medicare/Medical, which is a painful and long process.



It seems to the a rule for most private insurance companies; ex. BS of CA, Healthnet, Aetna, etc.

So you ARE planning on signing up for BCBS, Healthnet etc. etc. My recommendation for you then would be to log onto CAQH if you have not already and establish as much of a profile as you can. For other plans you wish to participate in who do not utilize CAQH as a credentialling mechanism, obtain their paper applications and fill out as much as you can so that on the day you are eligible to apply, you get it in quickly. You don't want to be phoning and requesting an application the day you are eligible. You want to be submitting them.

It is also prudent to try to pester medicare, medicaid as much as you can to expedite your application because many other 3rd party payors are going to require a medicare number.

It's a crappy process. Better you than me!

 

[orbitsurgMD]

Hello friends,

I am opening a practice as of July first. A couple of questions:

1. I don't want to buy an A-scan right of the bet and getting an IOL Master is quite expensive at first. What are the options for getting IOL calc in this situation? Send them to ASC or local ophthalmologists for these tests? Any other suggestions?

2. Billing . What's an acceptable rate for an outside billing company? I heard everything from 6 to 10% of collections.

3. Maybe this is a silly question, but what do people do before you get all the provider #? See pts for free? As far as I know you can only retrobill Medicare? Any info on that?

Thanks a lot.

You really should buy an A-scan and a suitable Praeger shell for its probe so you can do immersion A-scanning. Take a loan if you have to; it is a billable procedure and the cost of the device will eventually be covered. Look for a used unit if you need to. You can always make do with an AO keratometer which when bought used are cheap.

If you can, get a portable unit, especially if you are going into other doctors' offices or are servicing more than one location.

As to billing, that is the one thing you will have time for at the outset, when you aren't going to be that busy. You might as well hire yourself for that 6-10%.

BTW, outside billers like easy pickings--they are far more interested in submitting a new bill than they are in chasing rejects and repeat billings.

As for choosing insurance, Why Medical but not the Blues and major indemnity carriers? Medicaid would be the very last thing I would apply for when starting out.

 

[Eyefixer]

I am applying for Blues and other private companies, but I decided not to deal with manages care. I had a managed contract offered to me, that's why I brought it up.

Medical pays over $1k for cataract surgery, but clinic visits reimbursement is really low. I lot of my patients will have Medi/Medi, however.

Thanks for the info on a-scan. I'll look into that.

You really should buy an A-scan and a suitable Praeger shell for its probe so you can do immersion A-scanning. Take a loan if you have to; it is a billable procedure and the cost of the device will eventually be covered. Look for a used unit if you need to. You can always make do with an AO keratometer which when bought used are cheap.

If you can, get a portable unit, especially if you are going into other doctors' offices or are servicing more than one location.

As to billing, that is the one thing you will have time for at the outset, when you aren't going to be that busy. You might as well hire yourself for that 6-10%.

BTW, outside billers like easy pickings--they are far more interested in submitting a new bill than they are in chasing rejects and repeat billings.

As for choosing insurance, Why Medical but not the Blues and major indemnity carriers? Medicaid would be the very last thing I would apply for when starting out.

 

[orbitsurgMD]

I am applying for Blues and other private companies, but I decided not to deal with manages care. I had a managed contract offered to me, that's why I brought it up.

Medical pays over $1k for cataract surgery, but clinic visits reimbursement is really low. I lot of my patients will have Medi/Medi, however.

Thanks for the info on a-scan. I'll look into that.

MediCal won't be giving you $1K for a typical cataract. They will likely give you the 20% that Medicare does not cover of the Medicare allowable for the patients that are Medicare/MediCal. You will not likely have many cataract patients with MediCal alone--probably none--unless you plan on doing pediatric cataracts. Most disabled people have Medicare as primary. Medicare will then establish your payment limit, not MediCal.

You can get swamped in clinic by taking Medicaid. In most places, unless you keep a very tight rein on how many appointments for Medicaid patients you book, you may find yourself in your own self-imposed sweatshop. Trust me on this, I have been there and it is no fun at all.

 

[Eyefixer]

I am exactly sure what state you are in, but MediCAL is MediCAID in CA; it's the same thing.

Just because of specific patient population I'll be serving ( I am fluent in a 2nd language ), I will have some older patients with straight Medical. Not fun, I know, but you can't be picky in a competitive market where I am starting out.

For a standard cataract surgery Medical sends you a check for $1050; pre-approval is required, however.

 

[orbitsurgMD]

I am exactly sure what state you are in, but MediCAL is MediCAID in CA; it's the same thing.

Just because of specific patient population I'll be serving ( I am fluent in a 2nd language ), I will have some older patients with straight Medical. Not fun, I know, but you can't be picky in a competitive market where I am starting out.

For a standard cataract surgery Medical sends you a check for $1050; pre-approval is required, however.

I am aware that Medicaid in California is called MediCal. And I am sure you are correct in that their schedule for a cataract extraction and IOL is what you say it is. Most of your cataract patients will be old enough to have Medicare as their primary coverage, however. Some perhaps may be younger and depend on private indemnity or in some cases MediCal alone. For those (few), you will probably get the $1,050 you expect. For the folks who have Medicare as their primary--the bulk of the patients with cataracts in most places--the amount you will receive from CMS/Medicare will be the Medicare allowable for your region (assuming you accept assignment), less 20%, which is the responsibility of the patient or the patient's secondary carrier to pay. Even if the secondary insurance is MediCal, you won't get more than that 20%. So if Medicare allows $725 for a cataract, you will get $580 from Medicare and will have to collect that $145 from the patient, or from MediCal if that is their secondary carrier. You won't get $1050, that is for sure. If you don't take assignment, Medicare still limits what you can collect from Medicare beneficiaries to 15% over the "allowable" as a ceiling (e.g. $833.75 using these hypothetical figures) unless you "opt-out" of Medicare altogether and work as a private contractor.

Opting-out is something you will almost certainly not be able to afford to do, which is what Medicare and the federal government intends. It basically means that if you decide to charge what you want for your service, you have to get a written agreement from each patient that has Medicare acknowledging that they will not be eligible for any reimbursement at all from Medicare for the procedure (called robbing the taxpayer, IMO.) Further you as a physician become ineligible to receive any payment from Medicare for a two year period following your first private contract date, for any service you render to any Medicare-eligible patient. It is meant to be prohibitive and it is.


I am not telling you not to accept MediCal, if that is what you want. But you should not be expecting to make good on underpaid office services based on an expectation that you will have enough $1050 cataract procedures to make the overall effort worthwhile.

 

[Eyefixer]

orbitsurgMD,

You are correct in everything you said. I guess I was not making it clear in the previous posts. All I am saying is I will be seeing some Medicare-age patients who are not eligible for Medicare because of immigration status (non-citizens with greencards). These patients have Medical as Primary insurance and nothing else. Doing cataract surgery on these patients requires Medical pre-approval (can take up to 30 days). If the surgery is approved you are paid around $1050.

I am aware that Medicaid in California is called MediCal. And I am sure you are correct in that their schedule for a cataract extraction and IOL is what you say it is. Most of your cataract patients will be old enough to have Medicare as their primary coverage, however. Some perhaps may be younger and depend on private indemnity or in some cases MediCal alone. For those (few), you will probably get the $1,050 you expect. For the folks who have Medicare as their primary--the bulk of the patients with cataracts in most places--the amount you will receive from CMS/Medicare will be the Medicare allowable for your region (assuming you accept assignment), less 20%, which is the responsibility of the patient or the patient's secondary carrier to pay. Even if the secondary insurance is MediCal, you won't get more than that 20%. So if Medicare allows $725 for a cataract, you will get $580 from Medicare and will have to collect that $145 from the patient, or from MediCal if that is their secondary carrier. You won't get $1050, that is for sure. If you don't take assignment, Medicare still limits what you can collect from Medicare beneficiaries to 15% over the "allowable" as a ceiling (e.g. $833.75 using these hypothetical figures) unless you "opt-out" of Medicare altogether and work as a private contractor.

Opting-out is something you will almost certainly not be able to afford to do, which is what Medicare and the federal government intends. It basically means that if you decide to charge what you want for your service, you have to get a written agreement from each patient that has Medicare acknowledging that they will not be eligible for any reimbursement at all from Medicare for the procedure (called robbing the taxpayer, IMO.) Further you as a physician become ineligible to receive any payment from Medicare for a two year period following your first private contract date, for any service you render to any Medicare-eligible patient. It is meant to be prohibitive and it is.


I am not telling you not to accept MediCal, if that is what you want. But you should not be expecting to make good on underpaid office services based on an expectation that you will have enough $1050 cataract procedures to make the overall effort worthwhile.

 

[orbitsurgMD]

orbitsurgMD,

You are correct in everything you said. I guess I was not making it clear in the previous posts. All I am saying is I will be seeing some Medicare-age patients who are not eligible for Medicare because of immigration status (non-citizens with greencards). These patients have Medical as Primary insurance and nothing else. Doing cataract surgery on these patients requires Medical pre-approval (can take up to 30 days). If the surgery is approved you are paid around $1050.

Another thing: I don't know how well funded the State of California keeps its MediCal program, but in other states, like mine, the Medicaid agency frequently runs out of funds well before the end of the fiscal year. When they are getting close to vapor lock, they stop paying claims except those that are in their estimation critical. What that means is that you don't get that check you are expecting for the surgery you did, maybe for several months, and maybe not at all. Ophthalmology does not rate highly on the critical service hierarchy when funds dry up, no matter what the clinical consequences.

As I said, take MediCal if you want, but I recommend you watch your billing and collections patterns with them like a hawk.

 

[Eyefixer]

Point wll taken, thanks.

On another topic, is anyone familiar with this

http://www.optovue.com/RTVUE.asp?CC=Rtv

I am evaluating OCT machines and this is $9000 cheaper than Zeiss (it has both retina and ON software)

Another thing: I don't know how well funded the State of California keeps its MediCal program, but in other states, like mine, the Medicaid agency frequently runs out of funds well before the end of the fiscal year. When they are getting close to vapor lock, they stop paying claims except those that are in their estimation critical. What that means is that you don't get that check you are expecting for the surgery you did, maybe for several months, and maybe not at all. Ophthalmology does not rate highly on the critical service hierarchy when funds dry up, no matter what the clinical consequences.

As I said, take MediCal if you want, but I recommend you watch your billing and collections patterns with them like a hawk.

 

[Wolverine98]

You really should buy an A-scan and a suitable Praeger shell for its probe so you can do immersion A-scanning. Take a loan if you have to; it is a billable procedure and the cost of the device will eventually be covered

Another reason it's good to have an A-scan is that there are a fair number of patients on which you can't get a reading at all with the IOL master, for a variety of reasons. There are also times when you just don't feel confident about the IOL master measurements (such as a significant difference in size), and it's nice to have your own A-scan for those situations.

 

[KHE]

Point wll taken, thanks.

On another topic, is anyone familiar with this

http://www.optovue.com/RTVUE.asp?CC=Rtv

I am evaluating OCT machines and this is $9000 cheaper than Zeiss (it has both retina and ON software)

An OCT? For a start up practice?

I certainly don't know your situation or your market place but I have helped a local young ophthalmologist get his practice off the ground....let me make a suggestion:

Take little bites, my friend. Take little bites. An OCT is not needed for a start up practice, especially if you haven't gotten your credentialling issues sorted out. You don't want a $30000 machine sitting idly by while you wait to get paid to use it. Also, what is the lease going to be on a piece of equipment like that? Will you be able to do the 20-30 OCTs per month needed to cover a lease?

Start with the bare minimum of equipment needed and slowly add. Get only equipment that will generate immediate cashflow. Forego the electronic records for now since they don't generate revenue. Forego a fancy autorefractor/NCT for now. Train a technician to perform Goldmann. Do your own billing, or train your secretary to do it. Don't farm it out just yet for 6-10%. 6-10% right off the top for a start up practice is going to be HUGE, especially in the early months.

Again....small bites.

 

[orbitsurgMD]

Point wll taken, thanks.

On another topic, is anyone familiar with this

http://www.optovue.com/RTVUE.asp?CC=Rtv

I am evaluating OCT machines and this is $9000 cheaper than Zeiss (it has both retina and ON software)

Unless you are a retina specialist or have a huge startup fund on easy terms, an OCT would not be the first thing I would recommend you buy. You need an A-scan, probably a single lane of equipment, (with room enough for a second and third lane, but leave unfurnished at the outset), a small set or two of minor surgical instruments for office procedures, a cassette sterilizer (buy a used StatIM, they are a quarter the cost of new ones, and even the new ones break down), and a perimeter. The perimeter is more important starting out than an OCT and should be a priority. Everything else, including HRT, GDx, OCT, IOL Master, autorefractor, fundus camera and office lasers can wait until you are up and running and have some cash flow to afford without taking a lease or capital equipment loan. Look at the stuff at the bottom of most of the exam room desk drawers in your clinic lane and take note: you don't need that either.

Do you have a space yet?

 

[Eyefixer]

I am really grateful for all the "real world" advice I am getting here. My situation is a little more complex than just renting an empty space and starting a practice. Part of my arrangement is sub-leasing space in an office of a well-established optometrist (oh-oh! where is KHE ). He has everyting I need except for an a-scan, ON imaging, and minor procedure stuff. We have been talking about sharing cost of a Zeiss or an Optovue machine. This arrangement is part-time and is just my way of getting something of my own going.

Unless you are a retina specialist or have a huge startup fund on easy terms, an OCT would not be the first thing I would recommend you buy. You need an A-scan, probably a single lane of equipment, (with room enough for a second and third lane, but leave unfurnished at the outset), a small set or two of minor surgical instruments for office procedures, a cassette sterilizer (buy a used StatIM, they are a quarter the cost of new ones, and even the new ones break down), and a perimeter. The perimeter is more important starting out than an OCT and should be a priority. Everything else, including HRT, GDx, OCT, IOL Master, autorefractor, fundus camera and office lasers can wait until you are up and running and have some cash flow to afford without taking a lease or capital equipment loan. Look at the stuff at the bottom of most of the exam room desk drawers in your clinic lane and take note: you don't need that either.

Do you have a space yet?

 

[KHE]

I am really grateful for all the "real world" advice I am getting here. My situation is a little more complex than just renting an empty space and starting a practice. Part of my arrangement is sub-leasing space in an office of a well-established optometrist (oh-oh! where is KHE ). He has everyting I need except for an a-scan, ON imaging, and minor procedure stuff. We have been talking about sharing cost of a Zeiss or an Optovue machine. This arrangement is part-time and is just my way of getting something of my own going.

Well, that situation is a slightly different arrangement then. Are you going to be this ODs "guy" to handle all of his "non optometry" stuff? How many days a week are you planning on being there? Is it a solo OD office, or a muli-associate practice? Sharing the cost of an OCT may be a reasonable thing to do, but until you are sure of his/her practice you may want to simply pay a "per use" fee to do any OCTs that you need rather than entering into a shared payment type of arrangement.

You said "part of the arrangement" is the sub leased space. What's the "other" part?

 

[Eyefixer]

Well, that situation is a slightly different arrangement then. Are you going to be this ODs "guy" to handle all of his "non optometry" stuff?

yes, I hope

How many days a week are you planning on being there?

2/week initially

Is it a solo OD office, or a muli-associate practice?

Solo

 

[KHE]

Well, that situation is a slightly different arrangement then. Are you going to be this ODs "guy" to handle all of his "non optometry" stuff?

yes, I hope

How many days a week are you planning on being there?

2/week initially

Is it a solo OD office, or a muli-associate practice?

Solo

I would proceed with caution. I don't know what the arrangement you have made here with this doctor is, or what other plans you have but I am HIGHLY skeptical that any solo OD has enough "ophthalmolgical" patients in their practice to justify having an ophthalmologist in their office 2 days a week.

Unless you are thinking of forming a true partnership of some type with this OD, I'm not confident that this is going to be viable in the long term. Again, proceed with caution.

 

[orbitsurgMD]

I would proceed with caution. I don't know what the arrangement you have made here with this doctor is, or what other plans you have but I am HIGHLY skeptical that any solo OD has enough "ophthalmolgical" patients in their practice to justify having an ophthalmologist in their office 2 days a week.

Unless you are thinking of forming a true partnership of some type with this OD, I'm not confident that this is going to be viable in the long term. Again, proceed with caution.

This kind of arrangement could help or hurt, depending on the referral patterns in the community.
Referring medical doctors--primary care MDs-- won't care whether you share an office with an OD. All they will want is someone who can see their patient quickly and hopefully be taking the same insurance as the primary accepts. Other ODs might--you would be working for the competition from their point of view. You would have to be working for a very busy optometrist to expect to get much surgery by this arrangement alone. Does he own an optical on site?