Washington HCA / Medicaid

[pinipig523]

Just a question - is it still disallowed "balance billing" if you bill someone for whom no reimbursement has been given? Obviously, you won't necessarily be able to collect much from (and might feel badly about billing) a Medicaid patient - but if their "insurance" declines to pay anything, is it still "balance billing"?

I think some states disallow balance billing but it is still in effect in some states.

But regarding this whole thread - it is definitely depressing. Are there any loopholes in this non-reimbursed care after 3 visits?

Is it 3 visits for the same complaint?

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[Pinner Doc]

I think some states disallow balance billing but it is still in effect in some states.

But regarding this whole thread - it is definitely depressing. Are there any loopholes in this non-reimbursed care after 3 visits?

Is it 3 visits for the same complaint?

Again- the 3 visit rule was shot down in the fall. Now they're not paying for *any* non-emergent visits. When it was in effect, there were some loopholes - unstable vital signs, ambulance patients, etc. 3 visits were for any non-emergent complaint.

 

[pinipig523]

Again- the 3 visit rule was shot down in the fall. Now they're not paying for *any* non-emergent visits. When it was in effect, there were some loopholes - unstable vital signs, ambulance patients, etc. 3 visits were for any non-emergent complaint.

Wait... I'm an idiot.

They're not paying for ANY non-emergent visit?

And what's the whole 3 visit issue then? Am I correct in my understanding that the 3 visit max was from before, but now ANY non-emergent visit is non-compensated?

How does this even fly????

 

[docB]

Just a question - is it still disallowed "balance billing" if you bill someone for whom no reimbursement has been given? Obviously, you won't necessarily be able to collect much from (and might feel badly about billing) a Medicaid patient - but if their "insurance" declines to pay anything, is it still "balance billing"?

My understanding is that it doesn't matter what if anything you get paid. It only matters what kind of insurance they have. If it's Medicare or Medicaid you can't balance bill per the rules of CMS. If they have another insurer and they are in certain states (e.g. CA) then you can't balance bill per the laws of that state. Wether or not you were ever paid in immaterial.

For example: A patient has Aetna. They have not met their deductible so they have to pay that before any insurance kicks in. They don't pay the deductible so you've gotten nothing. You still can't balance bill in CA.

 

[xaelia]

I see.

So, does anyone have a link to donate to whichever advocacy group will be fighting the insanity of federally mandated services for which the state refuses to pay?

 

[pinipig523]

I see.

So, does anyone have a link to donate to whichever advocacy group will be fighting the insanity of federally mandated services for which the state refuses to pay?

Yeah, who's fighting for us?

 

[Birdstrike]

.

 

[GeneralVeers]

There is no advocacy group. We're it. The AMA and other various physicians organizations have failed us. They work for themselves, in their best "political" interests, not physicians'. The AMA supported Obamacare!

We're on our own. We've got to figure this out on our own. There is no group that we can outsource these problems to while we passively ignore the mess at hand, so we can move forward and see patients with our blinders on.

That model, has gotten us here.

The solution? My opinion:

Doctors need to grow a set. Get angry. And refuse to take it anymore.

Nothing we do will matter. The hospitals have caught us by a certain set of rules. We can't do anything without violating our contracts with them.

- We can't negotiate, because we can't strike and have nothing to threaten the government with
- We can't use passive-aggressive measures because the hospitals won't allow it
- We are replaceable cogs in the machine based on the hospital CEO point of view
- We are too "nice" to actually do the things necessary to change the system

Therefore we will always be the scapegoats, and the first to bend over and take it.

 

[Birdstrike]

.

 

[docB]

Yeah, who's fighting for us?

Why our politicians are our representatives and always have our best interests at heart. And the lawyers. They are all officers of the court and everything they do is for the greater good.

2 - General Veers, have you stocked up on lube and red rubber balls, to make the ride a little smoother?

Those are the only things my hospital provides without demanding a study showing postivie ROI.

 

[Birdstrike]

.

 

[EctopicFetus]

Just an FYI there is no reason why doctors cant unionize. There is an actual physicians union though most of us are too busy struggling by the join it. I personally dont like unions but this is such a screw job it isnt even funny.

IF we could organize we sure could make a difference. What if all ED docs said if you dont change this we wont show up to work... see the problem is we feel this debt to society. We would feel bad. I feel for the people I care for but we must put our foot down and stand up for ourselves.

 

[deleted109597]

I've already told people to leave the state. When I was looking for jobs, I only looked at states with meaningful tort reform. I'm not going to go to a state where the litigation risk is still silly, and public opinion is going to be against you everywhere. So you would actually come out better with PR if you kept your house in Washington, but flew for locums jobs and simply refused to work in the state. Or just up and moved completely, but I can understand not doing that in this market.

In medical school in TN, they threatened to make us stay in the state for 5 years after residency accepting TennCare patients to "subsidize" the money the state used to teach us. Or we had the option to pay $500K to opt out. It didn't fail because it was stupid. It failed because the lawyers of the people not able to pay it were able to show that it was a tax burden on their salaries. That's pretty sad.

 

[pinipig523]

I've already told people to leave the state. When I was looking for jobs, I only looked at states with meaningful tort reform. I'm not going to go to a state where the litigation risk is still silly, and public opinion is going to be against you everywhere. So you would actually come out better with PR if you kept your house in Washington, but flew for locums jobs and simply refused to work in the state. Or just up and moved completely, but I can understand not doing that in this market.

In medical school in TN, they threatened to make us stay in the state for 5 years after residency accepting TennCare patients to "subsidize" the money the state used to teach us. Or we had the option to pay $500K to opt out. It didn't fail because it was stupid. It failed because the lawyers of the people not able to pay it were able to show that it was a tax burden on their salaries. That's pretty sad.

I hear ya bro... but I just don't want this precedent to start following me around.

WE SHOULD FORM OUR OWN UNION!

 

[la gringa]

it doesn't matter if you balance bill people w/ no credit or "things" to lose... so who cares if you balance bill medicaid pts? no one garnishes SSI or food stamps for unpaid bills!

pinipig - supposedly there were attempts to form a doc's union at our residency hospital. iirc, most of the big proponents were not who you'd want caring for you if you were sick... they tend to protect the weak and disincentivize doing a good job. just look at the nurses at said hospital... the few who give a damn take on the crap of the huge # that 1. suck or 2. don't give a damn.

 

[GeneralVeers]

I hear ya bro... but I just don't want this precedent to start following me around.

WE SHOULD FORM OUR OWN UNION!

Most of us are too nice to strike, or not show up to work. We would feel bad if people died.

We could always set up a scenario where the ER is minimally staffed during a strike, and that physician only sees true life or death emergencies.

The problem as I stated above is that the hospitals themselves would never allow this. They couldn't care less if we were paid in magic beans, as long as we show up for work and get good press-ganey scores. The hospital would likely fire any ER group who threatened a work action.

 

[deleted109597]

I agree that action needs to be taken, but unionizing is not the answer. Unions exist now simply to increase pay and decrease the amount of work people do. This isn't the 1890s, children aren't getting limbs cut off in textile mills (in this country anyway).
Unionizing would decrease our image to many of the public. What we need is to get together and push for legislation to stop this kind of thing. Or, alternatively, simply allow the free market to work, and places where docs work for free will simply close down as they aren't making money, and aren't able to staff those joints.

 

[GeneralVeers]

I agree that action needs to be taken, but unionizing is not the answer. Unions exist now simply to increase pay and decrease the amount of work people do. This isn't the 1890s, children aren't getting limbs cut off in textile mills (in this country anyway).
Unionizing would decrease our image to many of the public. What we need is to get together and push for legislation to stop this kind of thing. Or, alternatively, simply allow the free market to work, and places where docs work for free will simply close down as they aren't making money, and aren't able to staff those joints.

The free market already largely works like that. There's a reason that low-volume, rural hospitals with poor reimbursement are hard to staff. It will be interesting to see what happens in the larger cities like Seattle and Tacoma with this legislation.

 

[EctopicFetus]

Related to balance billing.. There seems to be a number of people on here who dont understand what it is.

You cant balance bill medicare or medicaid because you or your group have agreed to what they are paying you. You can balance bill people if your group (or you) dont contract with.

Ill give 2 examples I contract with Blue Cross and they agree to pay me $200 for a level 5 visit. I CAN NOT balance bill them. I have agreed to a rate with them.

Say I dont contract with Aetna.. I see a patient with their insurance and they pay me $300 (they have a formula for what they pay non contracted physicians) for a level 5. If my normal rate is 400 for a level 5 visit I can balance bill that patient for the extra $100.

This is one of those things that drives people nuts. The numbers I used arent accurate but this is totally what happens.

 

[docB]

Related to balance billing.. There seems to be a number of people on here who dont understand what it is.

You cant balance bill medicare or medicaid because you or your group have agreed to what they are paying you. You can balance bill people if your group (or you) dont contract with.

Ill give 2 examples I contract with Blue Cross and they agree to pay me $200 for a level 5 visit. I CAN NOT balance bill them. I have agreed to a rate with them.

Say I dont contract with Aetna.. I see a patient with their insurance and they pay me $300 (they have a formula for what they pay non contracted physicians) for a level 5. If my normal rate is 400 for a level 5 visit I can balance bill that patient for the extra $100.

This is one of those things that drives people nuts. The numbers I used arent accurate but this is totally what happens.

You are correct. We don't balance bill plans we have a provider agreement with including CMS which everyone has an agreement with. Balance billing only applies to a small percentage of patients. The concern on our part and the reason we fight anti-balance billing legislation so hard is that it creates a slippery slope. Once you are not allowed to balance bill insurers have no reason to negotiate a reasonable fee. For example if Blue Cross decides it will only pay $5 for a Level 5 visit you can't go after their insured for the difference. You can take your $5 and you have no other recourse.

 

[EctopicFetus]

You are correct. We don't balance bill plans we have a provider agreement with including CMS which everyone has an agreement with. Balance billing only applies to a small percentage of patients. The concern on our part and the reason we fight anti-balance billing legislation so hard is that it creates a slippery slope. Once you are not allowed to balance bill insurers have no reason to negotiate a reasonable fee. For example if Blue Cross decides it will only pay $5 for a Level 5 visit you can't go after their insured for the difference. You can take your $5 and you have no other recourse.

Yes. I understand why it is important. Otherwise insurers wouldnt care if we contracted with them. They would unilaterally set the rates (much like CMS does).

I was just trying to clarify a point many on here seemed to not understand.

 

[Pinner Doc]

http://seattletimes.nwsource.com/html/localnews/2017449883_emergency08m.html

Finally, this makes the papers?

 

[Redrox]

http://seattletimes.nwsource.com/html/localnews/2017449883_emergency08m.html

Finally, this makes the papers?

Here's the key, misleading and d*ckish quote from the state Medicaid Chief Medical Officer:

"The ER physicians and hospitals have been abusing their privileges as providers of ER services for years, having the state pay for non-medically necessary services in the ER," Thompson said.

"They have not stepped up as leaders to actually be better stewards of care and safety and the public resources," he said.

WTF

 

[GeneralVeers]

Here's the key, misleading and d*ckish quote from the state Medicaid Chief Medical Officer:

"The ER physicians and hospitals have been abusing their privileges as providers of ER services for years, having the state pay for non-medically necessary services in the ER," Thompson said.

"They have not stepped up as leaders to actually be better stewards of care and safety and the public resources," he said.

WTF

I'm sure he knows better. ER physicians are an easy scapegoat in which to place blame for this as the public has little sympathy for us "rich" ER physicians, many of whom are in the dreaded "top 1%". He sets up the straw man of ER physicians seeing patients for non-urgent complaints, which then justifies the extreme actions of the state.

 

[Apollyon]

Here's the key, misleading and d*ckish quote from the state Medicaid Chief Medical Officer:

"The ER physicians and hospitals have been abusing their privileges as providers of ER services for years, having the state pay for non-medically necessary services in the ER," Thompson said.

"They have not stepped up as leaders to actually be better stewards of care and safety and the public resources," he said.

WTF

WTF, exactly. Patient comes to ED for BS, I see them as required by federal law, and I am abusing the system by "having the state pay" - because the patient has the state-provided MedicAid, and they bring their card (or don't). Otherwise, treat them for free. Right.

 

[WilcoWorld]

Here's the key, misleading and d*ckish quote from the state Medicaid Chief Medical Officer:

"The ER physicians and hospitals have been abusing their privileges as providers of ER services for years, having the state pay for non-medically necessary services in the ER," Thompson said.

"They have not stepped up as leaders to actually be better stewards of care and safety and the public resources," he said.

WTF

 

[alphaholic06]

Here's the key, misleading and d*ckish quote from the state Medicaid Chief Medical Officer:

"The ER physicians and hospitals have been abusing their privileges as providers of ER services for years, having the state pay for non-medically necessary services in the ER," Thompson said.

"They have not stepped up as leaders to actually be better stewards of care and safety and the public resources," he said.

WTF

What a load of bull****!

 

[EM2BE]

Here's the key, misleading and d*ckish quote from the state Medicaid Chief Medical Officer:

"The ER physicians and hospitals have been abusing their privileges as providers of ER services for years, having the state pay for non-medically necessary services in the ER," Thompson said.

"They have not stepped up as leaders to actually be better stewards of care and safety and the public resources," he said.

WTF

I saw that part and was too scared to see their reasoning in the rest of the article. Because I'm sure we tell all those people to go to the ED for treatment for their unnecessary visits.

 

[Pinner Doc]

I saw that part and was too scared to see their reasoning in the rest of the article. Because I'm sure we tell all those people to go to the ED for treatment for their unnecessary visits.

Yeah, I was thinking that maybe we ought to reconsider having that guy in the statue of liberty outfit out on the street corner, doing pelvic thrusts and holding a large sign advertising our emergency room.

In all seriousness, as a new Washington state EP, this is in such stark contrast to where I did my residency, where ED wait times were posted on the highway. Come to our hospital! You can be seen for your hangnail in 8...no, 7 minutes!

 

[goodoldalky]

If I worked in Washington, I would pack up and leave, and let the good Doctor Thompson staff the ED.

 

[EM2BE]

Yeah, I was thinking that maybe we ought to reconsider having that guy in the statue of liberty outfit out on the street corner, doing pelvic thrusts and holding a large sign advertising our emergency room.

In all seriousness, as a new Washington state EP, this is in such stark contrast to where I did my residency, where ED wait times were posted on the highway. Come to our hospital! You can be seen for your hangnail in 8...no, 7 minutes!

Are you half packed and ready to move yet?

 

[Pinner Doc]

Are you half packed and ready to move yet?

Tempted. I have no ties here. Family is back in upstate New York (my parents and my in-laws).

I went on a rant tonight, but my husband thinks if I left right now I'd be cutting off my nose to spite my face. He thinks this will all settle out.

 

[deleted109597]

I went on a rant tonight, but my husband thinks if I left right now I'd be cutting off my nose to spite my face. He thinks this will all settle out.

The only way it will settle out is if the physicians in the state show that it will actually reduce care. Suddenly, all the Medicaid people who can't get appointments won't go to the ED.
Hell, if I were a manager of any ED in the state, I would opt out of Medicare/Medicaid if at all possible. Then you wouldn't be responsible under EMTALA either. Stop letting Medicaid people walk all over you. Win win. Suddenly, all those "unfortunate" Medicaid people who are actually abusing the system won't have their after hours, free medical care, and will have to wait 3 months or more to see the few PCPs who will see them. Pandemonium ensues.

Oh, and Pinner, it wouldn't be cutting off your nose to spite your face. The better analogy would be cutting off your nose because it was bitten by a rabid bat. Yes, it hurts you, but it keeps you from dying in the long run.