What is your insurance reimbursement rate?

[InvestingDoc]

To those of you who are solo practice or business owners. are you willing to share what your reimbursement rate is?

For private insurance I'm sitting at 80-100% of medicare with the biggest insurance payers paying the least.

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[deleted87716]

All of our commercial contracts pay more than Medicare. The only plan I see that pays less than Medicare is Tricare (and that's a minuscule proportion of my patients).

 

[Postictal Raiden]

Aside from Medicaid, I thought Medicare was the floor. Damn.

 

[deleted87716]

Medicaid would definitely be the floor, but I don't accept Medicaid.

 

[Printer5000]

Private insurance paying less than Medicare? Why would an established practice accept that? That sounds terrible.

 

[deleted87716]

Rhode Island had that problem at one time. They still might.

 

[InvestingDoc]

When I went to get credentialed with the big boys, none of them in Texas were paying at least Medicare. They all are paying at least 10% under medicare. BCBS is paying 95% medicare and that is the highest. Smaller plans are all paying 100% medicare.

I tried to fight with them but they basically said look you're a one man operation. This is what we offer for primary care. Take it or choose not to be in network with us.

Cigna and Humana are paying 80% medicare and are my lowest.

 

[InvestingDoc]

All of our commercial contracts pay more than Medicare. The only plan I see that pays less than Medicare is Tricare (and that's a minuscule proportion of my patients).

What part of the US you in?

 

[Printer5000]

It is already hard enough to get students to go into primary care. That is ridiculous.

It sounds like OP should drop the private insurance and Medicaid and only see Medicare? Or else go DPC? Or sell out and go into a group practice - none of which sounds easy.

How does OP feel about that?

 

[deleted87716]

What part of the US you in?

SE Virginia.

 

[InvestingDoc]

It is already hard enough to get students to go into primary care. That is ridiculous.

It sounds like OP should drop the private insurance and Medicaid and only see Medicare? Or else go DPC? Or sell out and go into a group practice - none of which sounds easy.

How does OP feel about that?

Medicare makes up only around 20% of my current patient load so this would be a huge problem for me right now. As for going DPC, 4 local doctors (within 15 minute drive from me) have recently sold to MDVIP or other DPC model so competition would be tough.

I'm hiring another doctor now since I'm booked up quite well so I hope that once she joins that I can renegotiate a contract. I'm not sure how frequently they will negotiate with me though.

Taking 80% medicare for Cigna hurts every time I see one of their patients. I actually lose money on some vaccines with Cigna patients.

 

[septoplasty]

It is already hard enough to get students to go into primary care. That is ridiculous.

It sounds like OP should drop the private insurance and Medicaid and only see Medicare? Or else go DPC? Or sell out and go into a group practice - none of which sounds easy.

How does OP feel about that?

This is a really interesting statement, because this is usually a sought after thing.. surprising the OP faces this, yet unsurprising as health insurers, and hospitals sort of "merge", they want to reel in the 'fish', which happens to be us so that we have no choice but to be employed.

 

[Freezeout]

The group I work for just recently went out of network with Cigna in Texas....I assume it’s related to their reimbursement rates. Just reached agreement to go back in network.

 

[deleted87716]

The group I work for just recently went out of network with Cigna in Texas....I assume it’s related to their reimbursement rates. Just reached agreement to go back in network.

Sometimes ya' gotta play hardball.

 

[wamcp]

From WSJ today:

“The Trump administration is launching a program to offer new ways of paying primary-care doctors, including flat monthly payments to physicians and higher payments for medical practices specializing in the chronically ill, as a way to lessen the costs of Medicare’s usual fee-for-service system.

Seema Verma, the Medicare administrator under President Trump, said the flat-fee method and other payment alternatives could be a path for the Medicare payment system to achieve better outcomes for patients instead of the current fee-for-service method that creates “perverse incentives to offer more care.”

While the program is voluntary, the administration hopes that as many as one-fourth of all primary-care doctors will participate, Department of Health and Human Services Secretary Alex Azar said at a press conference Monday. The administration hopes that as many as 11 million Medicare beneficiaries also will be involved.

Tricia Neuman, director of the Kaiser Family Foundation’s program on Medicare policy, said the Medicare agency has been working for years to create payment incentives to lessen “unnecessary, high-cost care and reduce Medicare spending.” Whether the new payment models—part of which is set to go into effect next year—can do so, she said, will depend on the details as they evolve.

Adam Boehler, Medicare deputy administrator for innovation and quality, said the new, standard payment option for general-care doctors carries a downside risk of 10%, but an “upside potential of 50%,” based on patients’ risk-adjusted medical outcomes.

So, for example, he said, a doctor making $200,000 now could potentially make $300,000 under the plan if patients stay relatively healthy. The program begins in January of 2020.”

Anyone know if this is good or bad?

 

[VA Hopeful Dr]

Bad

 

[deleted87716]

"...as a way to lessen the costs of Medicare’s usual fee-for-service system."

Anyone know if this is good or bad?

"Lessen the costs" means pay us (healthcare providers collectively) less. How this will impact primary care remains unproven. Fortunately, the proposed payment models are voluntary. For now.

Primary Care First will provide payment to practices through a simplified total monthly payment to will allow clinicians to focus on caring for patients rather than their revenue cycle...primary care providers will get performance-based payment adjustments based on key outcomes on clinical quality measures, such as controlling high blood pressure, managing diabetes mellitus, and screening for colorectal cancer.

Sounds like capitation with risk.

The Direct Contracting payment model options are designed to create a competitive delivery system environment, CMS said.
Organizations offering greater efficiencies and better quality of care will be financially rewarded through a fixed monthly payment that can range from a portion of anticipated primary care costs to the total cost of care.Participants in the global payment model option will bear full financial risk, while those in the professional payment model option will share risk with CMS.

Sounds like something that would only appeal to health systems, along the lines of current ACOs.

The Geographic Population-Based option is designed to offer organizations the opportunity to assume responsibility for the total cost of care and health needs of a population in a defined target region.

Sounds like something aimed at underserved areas/FQHCs.

The risk part is nothing new. CMS has been moving towards that for a long time, and we're already in payment plans (e.g., ACOs) that have upside and downside potential. It remains to be seen whether any of these offer increased potential reimbursement.

 

[septoplasty]

if patients stay relatively healthy

Lol, isn't this basically how incentives are done currently w/ some commercial payers (i.e. A1c goals, exam goals etc.)?
This is idiotic because unless you have really motivated patients who actually care about themselves, you're going to miss this "mark" and "lose" this "incentive". The only scenario this works is in if everyone has healthcare, and people actually aren't deathly afraid of co-pays and medication costs to actually receive/undergo the care and are actually compliant (no, I don't like using the word 'adherent').

 

[FrustratedFamDoc]

From WSJ today:

“The Trump administration is launching a program to offer new ways of paying primary-care doctors, including flat monthly payments to physicians and higher payments for medical practices specializing in the chronically ill, as a way to lessen the costs of Medicare’s usual fee-for-service system.

Seema Verma, the Medicare administrator under President Trump, said the flat-fee method and other payment alternatives could be a path for the Medicare payment system to achieve better outcomes for patients instead of the current fee-for-service method that creates “perverse incentives to offer more care.”

While the program is voluntary, the administration hopes that as many as one-fourth of all primary-care doctors will participate, Department of Health and Human Services Secretary Alex Azar said at a press conference Monday. The administration hopes that as many as 11 million Medicare beneficiaries also will be involved.

Tricia Neuman, director of the Kaiser Family Foundation’s program on Medicare policy, said the Medicare agency has been working for years to create payment incentives to lessen “unnecessary, high-cost care and reduce Medicare spending.” Whether the new payment models—part of which is set to go into effect next year—can do so, she said, will depend on the details as they evolve.

Adam Boehler, Medicare deputy administrator for innovation and quality, said the new, standard payment option for general-care doctors carries a downside risk of 10%, but an “upside potential of 50%,” based on patients’ risk-adjusted medical outcomes.

So, for example, he said, a doctor making $200,000 now could potentially make $300,000 under the plan if patients stay relatively healthy. The program begins in January of 2020.”

Anyone know if this is good or bad?

Any time I read "lower the cost of healthcare," it always reads to me that the goal is to pay us less.

I wish instead of pushing doctors to become nannies and babysitters, there would be a push of people to own their health with incentives/penalties. Many of the high utilizers of resources do so because they either pay nothing (large amount), have taken poor care of themselves and continue to do so (also a large number), have crappy luck or are reaching the sunset years of their life and things just happen.

A good mechanic can only do so much when drivers are asleep at the wheel and crashing all the time.

Politically I get it, we're an easy target. Politicians can't exactly go out and tell their voter base you're overweight, don't take your meds, you eat like crap, smoke like freight trains and are breaking the system. It's much more politically savvy to blame those money hungry cold hearted docs (who don't pay enough taxes).

 

[deleted941485]

There was an article on medscape today that basically says all those incentive bonus program payments that were supposed to be made will probably never actually materialize. You could jump through all these mandated hoops today but the government could easily turn around and say “sorry we are broke no bonus for you”. Anybody taking govt insurance and is in these types of alternate payment programs should probably should be ready for some serious disappointment. In the long run it’s just an elaborate shell game. Heads CMS always wins tails you lose.

If you get a crappy risk pool and your patients get repeatedly hospitalized and sick what do you do then? Tell them please don’t go to the hospital or I won’t get my bonus? Is there a special adjustment for that? If so will it even come close to cost of caring for these people?

 

[deleted87716]

There was an article on medscape today that basically says all those incentive bonus program payments that were supposed to be made will probably never actually materialize.

You mean this one?

CMS Offers New Risk-Based Payment Methods to PCPs

The government hopes that a quarter of Medicare primary care providers will participate in programs with shared-savings and capitation arrangements. It also has launched program to prepay large organizations.

www.medscape.com

Where did it say that?

 

[deleted941485]

You mean this one?

CMS Offers New Risk-Based Payment Methods to PCPs

The government hopes that a quarter of Medicare primary care providers will participate in programs with shared-savings and capitation arrangements. It also has launched program to prepay large organizations.

www.medscape.com

Where did it say that?

Payments "Not Achevable"?
Federal officials seem to agree with this view.
Routinely accompanying the trustees' report is an analysis by staff of the Centers for Medicare & Medicaid Services (CMS). Titled "Projected Medicare Expenditures Under an Illustrative Scenario With Alternative Payment Updates to Medicare Providers," this report delves into questions about how much the program might cost if Congress were to override its own previous efforts to control its spending.

The 2019 version of this CMS report notes that lawmakers will in the years ahead feel pressure to revisit recent laws that may curb growth in the program's spending.

I’ll admit a cynical interpretation but would not put it past them.

They’ll be pressured by seniors to maintain coverage but also by tax payers to control costs. If what they will pay out from these programs ends up being more than anticipated, you can bet they will balk.

Sorry that bonus is “not achievable” but here’s what we think we owe you (non negotiable of course).

 

[deleted87716]

They’ll be pressured by seniors to maintain coverage but also by tax payers to control costs.

You're kidding, right? More than half the country wants single-payer (e.g., "Medicare for all"). Nobody cares how much something will cost if they think it'll be paid for with somebody else's money.

Public Opinion on Single-Payer, National Health Plans, and Expanding Access to Medicare Coverage | KFF

For many years, Kaiser Family Foundation has been tracking public opinion on the idea of a national health plan (including language referring to Medicare-for-all since 2017). Historically, our polls have shown support for the federal government doing more to help provide health insurance for...

www.kff.org

 

[VA Hopeful Dr]

You're kidding, right? More than half the country wants single-payer (e.g., "Medicare for all"). Nobody cares how much something will cost if they think it'll be paid for with somebody else's money.

Public Opinion on Single-Payer, National Health Plans, and Expanding Access to Medicare Coverage | KFF

For many years, Kaiser Family Foundation has been tracking public opinion on the idea of a national health plan (including language referring to Medicare-for-all since 2017). Historically, our polls have shown support for the federal government doing more to help provide health insurance for...

www.kff.org

Check out slide 11 though.

You get a majority opposing it if it would: raise taxes, eliminate private insurance, or lead to delays in testing/treatment.

 

[deleted941485]

Check out slide 11 though.

You get a majority opposing it if it would: raise taxes, eliminate private insurance, or lead to delays in testing/treatment.

We want a public healthcare plan for all!! One that doesn’t involve putting any sort of actual means behind it but yeah it’s great! Just don’t ask me for more money ever Hahahaha. Screw those doctors.

It kind of reminds me of my town hall. Everybody has a complaint about the roads schools and sewer system and yet nobody will vote to raise taxes to fund it.


I also love how the comment section of that med scape article became just a justification for single payer. Lol.

 

[deleted87716]

You get a majority opposing it if it would: raise taxes, eliminate private insurance, or lead to delays in testing/treatment.

Which it would, of course, as it has in every other country that's done it.

 

[deleted941485]

You're kidding, right? More than half the country wants single-payer (e.g., "Medicare for all"). Nobody cares how much something will cost if they think it'll be paid for with somebody else's money.

Public Opinion on Single-Payer, National Health Plans, and Expanding Access to Medicare Coverage | KFF

For many years, Kaiser Family Foundation has been tracking public opinion on the idea of a national health plan (including language referring to Medicare-for-all since 2017). Historically, our polls have shown support for the federal government doing more to help provide health insurance for...

www.kff.org

That’s the selling point! They’re gonna stick it to the rich. So what does the average person care? I think somebody said like new levy on people with over 50 millions dollars in wealth. Of course it’ll be a different story when the govt finds that won’t be enough and they’ll need to start taxing ordinary people.

 

[deleted941485]

Which it would, of course, as it has in every other country that's done it.

But but but...the public option for Medicare buy in. That’ll provide real “competition” in the market. Real healthcare choice.

When your competition has the guns, makes the rules, has sovereign immunity and can literally print money. Nobody stands a chance.

 

[deleted87716]

Regardless of what is proposed, every government employee should be required to use it, including Congress and the President.

 

[deleted941485]

Regardless of what is proposed, every government employee should be required to use it, including Congress and the President.

Whatever is proposed there will be Medicare and then there will be “Medicare”. Commercial insurance will be make up like 10% of the market if that.

 

[deleted87716]

Whatever is proposed there will be Medicare and then there will be “Medicare”. Commercial insurance will be make up like 10% of the market if that.

I’m cool with letting government employees buy private insurance, as long as it’s paid for out of their own pocket.

 

[deleted941485]

I’m cool with letting government employees buy private insurance, as long as it’s paid for out of their own pocket.

Lol the next couple years are gonna be a real roller coaster!