What percentage of your family medicine patient volume is medicaid/medicare?

[Faebinder]

Curious to see how the numbers are out there....

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[deleted87716]

I didn't answer your poll, because Medicaid and Medicare are not the same thing.

I do not take Medicaid.

Medicare makes up approximately 30% of my total charges. I'm not accepting any new Medicare patients at this time.

 

[Faebinder]

Well thanks for letting us know... I don't differentiate between the two as both are 100% government controlled and both are worse than regular insurance... So I would be interested to know how much of everyone's practice is government controlled pay.

 

[deleted87716]

I don't differentiate between the two

Bad idea.

Anyway, nobody forces anyone to see Medicaid or Medicare patients. You have to analyze it like any other business decision. There are non-monetary factors involved, of course.

 

[RuralMedicine]

Roughly ? [I could probably get my biller to print it out stratified by payer source which we will need to do at the end of the year but I'm responding off cuff. It actually bothers me that I can do this to an extent because ideally providers would be payer source blinded. However, since which brand of various medications, how we precertify etc is based on your payer source I can do this from the top of my head.]

Pediatrics:
10% Straight Medicaid
20% Medicaid HMO (Of our two big ones they both pay about the same but if you have a child that needs any workup or equipment I'm going to hope and pray you picked a certain one because I'll practically be promising my own first born to get your kid a nebulizer if you didn't).
45% CHIPs
10% State Employees Benefit Plan (Some of the CHIPs kids have this as a secondary as well)
15% Blue Cross & Blue Shield (including a few other random commercial insurance here probably)

IM
15% Self-Pay (a few medical savings accounts in here but mostly no insurance struggling to pay)
35% Medicare
20% Blue Cross & Blue Shield
20% State Employees Benefit Plan
10% Medicaid

Yeah it's a great payer mix It's called more emphasis on serving the community than making money. Yes, I realize that I'm allowing the facade of our broken health care system to continue and I'm all for us fixing the problems I'm just not willing to turn my back on patients while we do. (I'm also smart enough to realize that my rural poor patients going without isn't going to influence the congressional process one whit. Now if I was refusing to take Medicare in an upscale suburb of DC then perhaps I'd be solving the problem.) I'll be the first to admit I don't want to be a martyr and I'm not taking a complete vow of poverty to practice medicine if my practice prohibits me from supporting myself/family then obviously things will change. At the moment I can make things work and I suppose I'm optimistic that I'll survive the worse times ahead and we will ultimately fix our broken health care system. I can dream

 

[Faebinder]

Wow, some medical saving accounts do exists out there...

How is the charging of those? Do you charge full price and they pay full price? Just curious... heard of them but never seen the action. I'm interested in them for my own insurance in the future.

 

[RuralMedicine]

Wow, some medical saving accounts do exists out there...

How is the charging of those? Do you charge full price and they pay full price? Just curious... heard of them but never seen the action. I'm interested in them for my own insurance in the future.

Legally you have to use the same fee schedule regardless of payer source (the difference is that your commercial/medicaid etc can basically give you a percentage of your fee schedule or set maximums). So they pay what my fee schedule is (unless their income allows them to meet sliding fee criteria which off the top of my head I can't think of anyone at the moment in that group). They subsidize my self pay-unable to pay group a little (although unfortunately the unable to pay patients exceed the medical savings account patients).

 

[deleted87716]

Legally you have to use the same fee schedule regardless of payer source (the difference is that your commercial/medicaid etc can basically give you a percentage of your fee schedule or set maximums). So they pay what my fee schedule is (unless their income allows them to meet sliding fee criteria which off the top of my head I can't think of anyone at the moment in that group). They subsidize my self pay-unable to pay group a little (although unfortunately the unable to pay patients exceed the medical savings account patients).

Aside from a sliding fee, another option is to offer a discount for cash (e.g, pay your bill in full at the time of service and get a 20% discount off the standard fee schedule). The supposed justification for this is that you don't incur the overhead associated with billing, so you can charge a little less. You have to offer it to everyone, though...even patients who have insurance. You'll need to inform these folks that if they pay cash up-front and receive the discount, neither you nor they can submit an insurance claim for those charges...this would constitute fraud. You also wouldn't collect any co-payments in those situations. Admittedly, this probably wouldn't happen very often...most of the people who used the discount for cash would be self-pay. It also wouldn't apply to "budget plans," which is when you allow a patient to pay off their balance in several installments. The cash discount only applies when they pay in full at the time of service.

Lots of people outside the practice of medicine don't realize that we are allowed to have only have one fee schedule, and we set the prices ourselves.

However, when you contract with a third-party payor (whether it's the government or a commercial insurance company), you agree to accept what they pay...what's known as "discounted fee for service," which is always something less than your published fee schedule (if you're doing it right).

You create your fee schedule based on what the best-paying insurance will reimburse you for each individual CPT code. For example, if Medicare pays you $30 for "Code X", and the highest-paying BCBS plan pays you $45 for the same service, you set your fee schedule at $46 or above. That way, you will capture the maximum reimbursement from all payors. Because of this, your "collection percentage" for Medicare will be lower than BCBS, which is why it pays to have a good payor mix.

If you weren't paying attention, and your published fee for "Code X" was only $40...that's the most you'd ever get paid, even though BCBS was willing to pay $45. Believe it or not, many doctors are leaving money on the table this way. It's important to review your fee schedule regularly in comparison to your payors' fee schedules in order to prevent this.

 

[Faebinder]

Aside from a sliding fee, another option is to offer a discount for cash (e.g, pay your bill in full at the time of service and get a 20% discount off the standard fee schedule). The supposed justification for this is that you don't incur the overhead associated with billing, so you can charge a little less. You have to offer it to everyone, though...even patients who have insurance. You'll need to inform these folks that if they pay cash up-front and receive the discount, neither you nor they can submit an insurance claim for those charges...this would constitute fraud. You also wouldn't collect any co-payments in those situations. Admittedly, this probably wouldn't happen very often...most of the people who used the discount for cash would be self-pay. It also wouldn't apply to "budget plans," which is when you allow a patient to pay off their balance in several installments. The cash discount only applies when they pay in full at the time of service.

Lots of people outside the practice of medicine don't realize that we are allowed to have only have one fee schedule, and we set the prices ourselves.

However, when you contract with a third-party payor (whether it's the government or a commercial insurance company), you agree to accept what they pay...what's known as "discounted fee for service," which is always something less than your published fee schedule (if you're doing it right).

You create your fee schedule based on what the best-paying insurance will reimburse you for each individual CPT code. For example, if Medicare pays you $30 for "Code X", and the highest-paying BCBS plan pays you $45 for the same service, you set your fee schedule at $46 or above. That way, you will capture the maximum reimbursement from all payors. Because of this, your "collection percentage" for Medicare will be lower than BCBS, which is why it pays to have a good payor mix.

If you weren't paying attention, and your published fee for "Code X" was only $40...that's the most you'd ever get paid, even though BCBS was willing to pay $45. Believe it or not, many doctors are leaving money on the table this way. It's important to review your fee schedule regularly in comparison to your payors' fee schedules in order to prevent this.

How do the insurance companies provide you with their reimburisment for icd codes? they give you a booklet? or a cd or what exactly? What about medicare?

Reason i am asking is wondering how hard would it be to put all this in an excel sheet and then change it according to the changes of the insurance company... that way you know the minimum you should bill.

 

[deleted87716]

How do the insurance companies provide you with their reimburisment for icd codes? they give you a booklet? or a cd or what exactly? What about medicare?

The data format varies (I've seen paper printouts, Excel spreadsheets, and CD-ROMs before), but all of our payors are required to provide us with a fee schedule before we'll sign a contract. Many of them simply base their fees on Medicare (e.g., they pay some percentage over Medicare's published fees.*) Our group administrator is a big Excel guy, so that's how he keeps everything straight. The fee schedules are also entered into our billing software, so that's how the system knows how much to charge.

You can access the Medicare fee schedule online: http://www.cms.hhs.gov/PhysicianFeeSched/

Since commercial payors negotiate their fee schedules, they're not usually available outside an individual practice. Physicians are also prohibited by law and contract from comparing fee schedules, lest they be accused of collusion and price-fixing.

*Edit: Typically, you'll contract with a payor based on the Medicare fee schedule at that point in time. This insulates you from changes in the Medicare fee schedule for the length of your contract, after which you must re-negotiate.

More info on negotiating with payors:
http://www.aafp.org/fpm/20061100/49nego.html
http://www.aafp.org/fpm/20041000/31cany.html
http://www.aafp.org/online/en/home/policy/privatesector/healthplan/contracting.html