State Reimbursement rates

[gecko]

I was trying to compare the level of private insurance reimbursement rates from state to state, but wasn't able to find any sources on the web.

Does anyone have any insight on this?

I have heard that California and Florida have some of the lowest reimbursements.

Does anyone know about WA state?

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[Aether2000]

I am not sure it is possible to draw meaningful conclusions regarding reimbursement rates averaged over an entire state. Typically, areas within a state that have a high HMO penetration will have pathetically low reimbursement rates such as Cincinnati where the HMO penetration is up to 80%. Singular insurers that have cornered a particular market will also frequently have low reimbursement rates such as Rochester. Sometimes areas with extreme competition between insurers and providers such as Phoenix may have low reimbursement. WC carriers in California have low reimbursement now, if you can get approval at all for procedures.
The financial class mix of your population may be responsible for the greatest factor in reimbursement. This varies considerably within a state.

 

[gecko]

Thanks algos for your input.

When "negotiating" with insurance companies regarding reimbursement rates, do you have any recommendations, or is it pretty much a "take it, or leave it" situation with these companies?

 

[Aether2000]

If you are the only game within a reasonable driving radius, you may stand a chance at negotiating higher fees. Some docs have been able to negotiate ASC facility fees or a lower version of these fees for doing injections in an office rather than an ASC, but Anthem/Blue Cross has short circuted that practice by slashing physician fees by 2/3 for pain procedures done in a hospital or ASC. Medicare does the same.
Otherwise, it is usually taking the fee schedule or dropping the insurance altogether.

 

[Xclamp]

Back to the original question, is there any resource out there that can compare different PRIVATE carriers, or the mean payouts (in various states)? Anybody can go to the Medicare/Medicaid website to find out about specific CPT codes for a given area, but what about other payors? Better yet, what states are "Pain" friendly? Thanks in advance, XC

 

[Disciple]

WC carriers in California have low reimbursement now, if you can get approval at all for procedures.

Getting stuff approved is the bane of my existance right now.

I just heard the reimbursement for dispensing meds to Worker's Comp patients (California) in the clinic is going to become "unprofitable" come December.

What's next?

 

[drrinoo]

algos,

my understanding is that physicians cannot discuss each other's reimbursements...or is it that they cannot collectively set fees....i.e., outside an IPA....collusion/antitrust....ironically, insurance companies are moving to post physicians fee schedules, after a physician has independently set his/her fees

but...it seems in areas where reimbursement is low, despite competition among carriers, MCOs can collude?

 

[lobelsteve]

algos,

my understanding is that physicians cannot discuss each other's reimbursements...or is it that they cannot collectively set fees....i.e., outside an IPA....collusion/antitrust....ironically, insurance companies are moving to post physicians fee schedules, after a physician has independently set his/her fees

but...it seems in areas where reimbursement is low, despite competition among carriers, MCOs can collude?

Physicians are free to discuss anything we so desire, but we cannot "come to the table" collectively. The legality of setting a reserve price (such as in an auction) would be questionable and would involve COOPERATION of all physicians in a specified cachement area to agree not to accept anything below the reserve.

 

[Aether2000]

There is often a fine line between collusion and discussion, however there is a safe way to achieve this information. There are services that collect this data for hospitals and surgery centers, and often these have physician fees associated. Some of the ASIPP lit and Mowles lit have a non-medicare price, listed. But the easiest way in a vicinity to derive this info is to pay a high school student to perform a market analysis via survey, with the proviso the info regarding fees and actual payments received for each procedure, will be posted on a website with practice/physician identifiers removed. This is perfectly legal and passes the sniff test for collusion.

 

[Disciple]

Getting stuff approved is the bane of my existance right now.

I just heard the reimbursement for dispensing meds to Worker's Comp patients (California) in the clinic is going to become "unprofitable" come December.

What's next?

Had yet another discogram denied today because the patient had not been "cleared" by a psychologist.

Injury was less than 1 year old, patient motivated to return to work, no signs of aberrant chronic "pain" behavior and patient not yet at MMI.

I don't know, I have a feeling alot of these reviewing pain docs deny my procedures then perform the same procedures on the same type of patients in their own practice.

 

[jsaul]

you are right because the more they deny the more they get paid