When to start seeing Tricare

[turkish]

I go on terminal leave May 1, start new job in private practice mid May. Still active duty until June 30. Can I start seeing Tricare before July 1? Hold and bill after that date? Pro bono? Bill under partner until that time? What do I do with my hands?

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[HighPriest]

I didn't start seeing Tricare until after my out date. Don't know if that was necessary. Try to limit the amount I see anyway, as it doesn't bill well.

 

[Gastrapathy]

TRICARE is such a nightmare to deal with, just avoid it altogether if you can. Otherwise, wait until your out date.

 

[militaryPHYS]

I bet those service members and beneficiaries would appreciate seeing a prior service doc.

 

[Gastrapathy]

Of course they would, the question is whether @turkish should pay for the privilege. The amount of effort to get paid is ridiculous and the rates are closer to Medicaid than Medicare. TFL is fine since they are a secondary payer for Medicare but the rest of it is terrible and actually a net loss.

 

[Chonal Atresia]

TRICARE is such a nightmare to deal with, just avoid it altogether if you can. Otherwise, wait until your out date.

Too bad the government and the services are not serious when they spout the party line of wanting the best care for active duty, dependents and retirees.

They know the situation regarding pay/reimbursement rates but don’t care. If they actually did care about getting these people seen in an efficient manner, rates would increase to at least the level of Medicare.

As an aside, we are close to an MTF and with the current changes we have seen an explosion in the number of ENT consults coming our way in the last two months (MTF has dropped from 5 docs to 2 and one is pregnant). I won’t get into the details why this has happened, but part of the reason is due to requirements of AD docs taking non-clinical command positions.

We limit our clinics to 1 Tricare/day and I think waiting time right now is 2 months and growing.

 

[pgg]

It'll be a moot point in 2021 when the newly inaugurated President Harris and VP Warren give us Medicare For All (at Tricare rates).

 

[d2305]

I'm looking forward to the debates. Her Indian heritage should be an ongoing topic.

 

[Apollyon]

I'm looking forward to the debates. Her Indian heritage should be an ongoing topic.

Sen. Harris or Sen. Warren? Are you talking subcontinent or Native American Indian?

 

[militaryPHYS]

It'll be a moot point in 2021 when the newly inaugurated President Harris and VP Warren give us Medicare For All (at Tricare rates).

No matter who is in office, I think within the next decade we will continue to see reimbursements drop and the dissolution of what is left of the private practice model. We are going to fall in line with European healthcare systems which is basically nationalized/socialized healthcare. We will be owned by the hospitals and paid a salary which will likely still be more than MilMed pays, but much less than current national averages.

 

[Chonal Atresia]

No matter who is in office, I think within the next decade we will continue to see reimbursements drop and the dissolution of what is left of the private practice model. We are going to fall in line with European healthcare systems which is basically nationalized/socialized healthcare. We will be owned by the hospitals and paid a salary which will likely still be more than MilMed pays, but much less than current national averages.

Doom and gloom!

I don’t believe this will happen. Americans want their medical care now and they want the best money can buy.

While it is true more physicians are electing to become employed, the majority are still in a private practice model.

I think the days of solo practice are over; however, private practice is not. IMO, the key to fighting hospital takeover is to merge and expand. More providers means more negotiating power with insurance companies.

My practice has 40+ surgeons (along with PAs and NPs) and generated over 65M in revenue last year. Practices like ours are going nowhere anytime soon.

 

[militaryPHYS]

Doom and gloom!

I don’t believe this will happen. Americans want their medical care now and they want the best money can buy.

While it is true more physicians are electing to become employed, the majority are still in a private practice model.

I think the days of solo practice are over; however, private practice is not. IMO, the key to fighting hospital takeover is to merge and expand. More providers means more negotiating power with insurance companies.

My practice has 40+ surgeons (along with PAs and NPs) and generated over 65M in revenue last year. Practices like ours are going nowhere anytime soon.

Touche! Thanks for calling me out on the doom and gloom.

I guess my real question is...how much of your practice is productivity based and how much is salary based? Obviously this is practice dependent, but don't you think that with continued decreased reimbursements across the board that merging and expanding will continue until there is a shift towards majority Wellspan or Kaiser like systems with mainly salary pay instead of productivity pay?

 

[Chonal Atresia]

Touche! Thanks for calling me out on the doom and gloom.

I guess my real question is...how much of your practice is productivity based and how much is salary based? Obviously this is practice dependent, but don't you think that with continued decreased reimbursements across the board that merging and expanding will continue until there is a shift towards majority Wellspan or Kaiser like systems with mainly salary pay instead of productivity pay?

Decreased reimbursements are certainly challenging, don’t get me wrong.

If we go to a strict salary-based system, productivity is going to plummet and wait times are going to soar. For instance, I had a thyroidectony cancel for my day in the OR tomorrow so I only have 1 thyroid while my partner has 2 ( we do these cases together). Instead of making it an early day and hitting the golf course around 2 PM (like I would have done in the military or if I was employed), I booked a clinic of 15 patients beginning at 2 PM.

Obviously this practice occurs millions of times over everyday for those of us in private practice. Take away the incentive to be productive and you take away patient access.

 

[militaryPHYS]

Decreased reimbursements are certainly challenging, don’t get me wrong.

If we go to a strict salary-based system, productivity is going to plummet and wait times are going to soar. For instance, I had a thyroidectony cancel for my day in the OR tomorrow so I only have 1 thyroid while my partner has 2 ( we do these cases together). Instead of making it an early day and hitting the golf course around 2 PM (like I would have done in the military or if I was employed), I booked a clinic of 15 patients beginning at 2 PM.

Obviously this practice occurs millions of times over everyday for those of us in private practice. Take away the incentive to be productive and you take away patient access.

100% agree. But the way healthcare is changing they aren't focused on access to care...they only care about perceived cost to patient and making sure doctors aren't making too much money. Backwards, but the media drives everything in this country. We may not have any control over the big policy changes

 

[Chonal Atresia]

100% agree. But the way healthcare is changing they aren't focused on access to care...they only care about perceived cost to patient and making sure doctors aren't making too much money. Backwards, but the media drives everything in this country. We may not have any control over the big policy changes

I see the public revolting if they have to wait a year to get their knee/hip replacement or 6 months to get tubes in their kid’s ears.

Maybe I’m wrong but I think there will always be a market for private practice in this country. I don’t think a strictly socialized model would be tolerated.

 

[militaryPHYS]

I'm not advocating for a socialized system but I think we all underestimate the current social trends of our country. We may not have a choice/voice

 

[deleted941485]

I'm not advocating for a socialized system but I think we all underestimate the current social trends of our country. We may not have a choice/voice

You don’t have a voice but you do have feet.

 

[armytrainingsir]

To answer the original question, the safe play is to wait until July 1.

As far as Tricare, I enjoy my Tricare patients; they tend to follow directions, keep appointments, pay their bills, and are appreciative that I take Tricare. All my AD patients live on the economy and I have been fortunate they refer their BC/BS neighbors.

As long as I can break even, I will continue to see them.

 

[Gastrapathy]

Are you really breaking even? That’s surprising given the gap we see. What rate of your initial submissions for payment are rejected by the TRICARE overlords.

BTW, breaking even is also known as working for free (but that would be better)

 

[militaryPHYS]

Those who couldn't stand the pitfalls of MilMed related to administrative tasks and decreased pay while active duty probably also don't want to deal with the hassles and decreased reimbursement related to Tricare in the civilian world.

 

[Gastrapathy]

A+ troll. Well done

 

[militaryPHYS]

How do you think it makes those of us who are still active duty with family members feel to see prior active duty guys complaining about Tricare patients? I'm glad you guys are having such a great time in the civilian world making lots of money with tons of freedom, but don't be surprised if you tick off those of us still on active duty with families sometimes.

The system sucks currently, but refusing to see active duty and family members because of poor reimbursement is a pretty lousy approach in my opinion.

 

[absolutdokta]

Doom and gloom!

I don’t believe this will happen. Americans want their medical care now and they want the best money can buy.

While it is true more physicians are electing to become employed, the majority are still in a private practice model.

I think the days of solo practice are over; however, private practice is not. IMO, the key to fighting hospital takeover is to merge and expand. More providers means more negotiating power with insurance companies.

My practice has 40+ surgeons (along with PAs and NPs) and generated over 65M in revenue last year. Practices like ours are going nowhere anytime soon.

A big plus one on the first part. My old man (originally started practicing in Canada) is in private practice, fam med, and does very well and is much happier than he was up north. He’s (patiently) waiting for me to finish my ADSO and take over when I get out. I haven’t decided exactly what I’m going to do when I get out....don’t tell him that. I’ve thought about going down the hospital-employed route. I’ve come to like paid time-off along with retirement plans and all. Yes I know I can set up retirement stuff and what not....but the automation of working for the government has made me not want to think much about it. Just keep depositing that money and I’ll keep working.

 

[Gastrapathy]

Ok. The government has decided to tax me for any TRICARE patient I see. My staff waste their time and when we get paid, we still lose money due to overhead.

And you have the gall to suggest that declining to pay that voluntary tax is a character issue.

Let me know when you write an extra check to the government because taking your full entitlement is a lousy approach. I served honorably. That doesn’t make the government entitled to more from me. But it’s comments like that which show how skeptical our impressionable minds should be. You actually believe that the government is entitled to tax me extra because I served. Good for you

 

[backrow]

How do you think it makes those of us who are still active duty with family members feel to see prior active duty guys complaining about Tricare patients? I'm glad you guys are having such a great time in the civilian world making lots of money with tons of freedom, but don't be surprised if you tick off those of us still on active duty with families sometimes.

The system sucks currently, but refusing to see active duty and family members because of poor reimbursement is a pretty lousy approach in my opinion.

How does it make one feel to know the government cares so little about your family that they refuse to pay a reasonable rate to ensure they have access to care?

That’s what irks me way more than doctors limiting the number of Tricare patients they see. The government should be willing to pay a premium for our family members.

 

[militaryPHYS]

I have no doubt you served honorably. Maybe talk with more respect for the people still serving when you discuss these issues and we wouldn’t have so much issue with your “tax” you have to pay now that you are out and making more money.

You, more than anyone understand what our service members sacrifice while serving. So don’t forget where you came from. Hearing that prior service docs so quickly write them off is valuable information for all of us.

 

[deleted480308]

How do you think it makes those of us who are still active duty with family members feel to see prior active duty guys complaining about Tricare patients? I'm glad you guys are having such a great time in the civilian world making lots of money with tons of freedom, but don't be surprised if you tick off those of us still on active duty with families sometimes.

The system sucks currently, but refusing to see active duty and family members because of poor reimbursement is a pretty lousy approach in my opinion.

As opposed to what approach?

If someone isn’t being paid appropriately for their time what do you want from them?

That’s not rhetorical. I’m actually confused what you would propose

 

[militaryPHYS]

As opposed to what approach?

If someone isn’t being paid appropriately for their time what do you want from them?

That’s not rhetorical. I’m actually confused what you would propose

Empathy? Selflessness and understanding that majority of these people have no idea what the government is doing for or to them. They just wanted to serve. You guys saw that with your junior officers and enlisted members.

Being angry at the system by taking it out on the victims of the system is the lousy approach. I could care less on what you feel entitled to as civilian physicians refusing to see military beneficiaries.

 

[deleted480308]

Empathy? Selflessness and understanding that majority of these people have no idea what the government is doing for or to them. They just wanted to serve. You guys saw that with your junior officers and enlisted members.

Being angry at the system by taking it out on the victims of the system is the lousy approach. I could care less on what you feel entitled to as civilian physicians refusing to see military beneficiaries.

Do you not see the juxtaposition of scolding someone for lack of empathy in the same paragraph where you say you “could care less” (I know you mean “couldn’t) that they are literally losing money to do what you are demanding from them?

This is govts problem. Promising people healthcare and then depending on patriotism and guilt to get docs to give the care for almost free is the flaw, not the doctors who resent the bad system

 

[militaryPHYS]

Expecting those who have never served to serve others isn't wise. Expecting patriots to continue to serve others I guess is just optimism. Not required, I understand that. I’d hope we all continue to find areas to serve the underserved. Continuing to care for our active duty and families despite low reimbursement I thought would be an easy way to continue to serve others.

Do you guys not do any pro bono or volunteering? Perhaps I expect too much of people.

 

[Gastrapathy]

It’s not charity to help DoD spend less. The govt already gets its share from me. As for our charitable work and donations, we give to people who are actually less fortunate rather than the multi billion $ military industrial complex.

You’ve said what a good financial deal the military is for you. I have just as much right expect you to give back part of your pay as you do to expect mine. None.

 

[Chonal Atresia]

Empathy? Selflessness and understanding that majority of these people have no idea what the government is doing for or to them. They just wanted to serve. You guys saw that with your junior officers and enlisted members.

Being angry at the system by taking it out on the victims of the system is the lousy approach. I could care less on what you feel entitled to as civilian physicians refusing to see military beneficiaries.

Being angry at reimbursement and limiting/refusing to take Tricare is the one of the only ways we can enact change.

Hopefully, the DoD will enact their proposed changes and start referring out more patients to “the network” and civilian physicians will limit Tricare even more. Maybe, just maybe, patients will actually complain enough and lobby Congress to increase reimbursement rates.

My one Tricare patient/day (out of 40+ ppd) generally does not complain because no other ENT practice for over 100 radius accepts Tricare at all.

You need to place your frustration with the real villain (US government) and not on your comrades. How can a country that spends more on its’ military than the next top 8 countries COMBINED not afford to pay reasonable reimbursement rates for healthcare?!

Easy for you criticize us for not taking Tricare when you don’t have employees counting on you for a paycheck to support their families. If you don’t like it, nobody is stoping you from buying supplemental insurance.

 

[Chonal Atresia]

Sorry for the misinformation.

Just the top 7 countries.

 

[militaryPHYS]

I already have directed my frustration with the government via local resources as well as through congressional delegate communication.

My frustration is with the system and I would have been happy to discuss that with you, but hearing that your approaches are basically just benign neglect of the patients in order to enact change is frustrating in itself.

Agree to disagree.

 

[Chonal Atresia]

I already have directed my frustration with the government via local resources as well as through congressional delegate communication.

My frustration is with the system and I would have been happy to discuss that with you, but hearing that your approaches are basically just benign neglect of the patients in order to enact change is frustrating in itself.

Agree to disagree.

Limiting the amount of Tricare that I accept because of poor reimbursement by our federal government is not the same as “benign neglect of patients.”
IMO (as well as several on this thread), it’s taking a stand against a broken system.

 

[Gastrapathy]

I don’t neglect my patients. Again, you have no right

 

[dwb8p]

militaryPHYS, why are you throwing shade at others, trying to make a living in the civilian world, when you've never had to do the same yourself?

 

[militaryPHYS]

One of the first responses in this thread was... "TRICARE is such a nightmare to deal with, just avoid it altogether if you can."

Sorry if I take offense to that. My point was don't be surprised if you tick some people off who are still on AD with families when you throw out stuff like that. Then, by claiming you are working hard to fix the system by refusing to see the Tricare beneficiary is literally the definition of benign neglect. There is a big difference between benign neglect and neglect.

Don't try to save face by saying you're helping those with Tricare by doing nothing. Just stick with the fact that it is bad for business and you won't get paid as much by seeing them. I could have expressed my opinion on that and let it lie. Claiming you're trying to help the very people you are refusing to see is a farce.

 

[Gastrapathy]

You insulted me before anyone wrote that. I’ll see TRICARE as soon as you return 10% extra to the government each month.

But don’t worry kids, he has your best interests at heart

Save face? With whom? You’ve jumped the shark this time

 

[militaryPHYS]

Disagreeing with you guys for refusing to see tricare isn’t an insult. It is my opinion. I’m sorry that someone disagreeing with you is insulting.

 

[j4pac]

Charity work? Get out of here.

This is about veterans livelihoods. Very few civilian physicians are even in the position to choose their own patient population. If you see high volume Tricare, your company loses money and you get your ass chewed.

I’m will be paid based on RVU, so my payor source doesn’t directly impact my pay. But you better believe that I’m going to lose my job if I’m not earning money for my institution. As much as I love military personnel, I’m not choosing them over my family. That’s an easy decision. The significant majority of military personnel would be perfectly understanding of that decision. Tricare needs to fix itself.

 

[Chonal Atresia]

Disagreeing with you guys for refusing to see tricare isn’t an insult. It is my opinion. I’m sorry that someone disagreeing with you is insulting.

Disagreeing with seeing Tricare is fine, insulting us for “abandoning patients” is not.

You are welcome to have a 100% Tricare/Medicaid practice when you get out. When you’ve never practiced outside the DoD and never been responsible for your own business/employees livelihoods, you have no clue how the real world works. Collections make businesses viable and Tricare collections suck.

Bark at us all you want, but it’s a fact.

 

[notdeadyet]

militaryPHYS- If you're going to be an SDN moderator, you might want to self-moderate a little. Slamming the patriotism and ethics of veterans on this forum because you don't like that they don't take Tricare is unprofessional and borders on TOS violation for moderators. Be classy.

 

[Cooperd0g]

militaryPHYS- If you're going to be an SDN moderator, you might want to self-moderate a little. Slamming the patriotism and ethics of veterans on this forum because you don't like that they don't take Tricare is unprofessional and borders on TOS violation for moderators. Be classy.

Well said. I was about to post something similar.

militaryPHYS, your general lack of knowledge and understanding of the overall issue with reimbursement is highlighted by your own responses.

 

[pgg]

The system sucks currently, but refusing to see active duty and family members because of poor reimbursement is a pretty lousy approach in my opinion.

Wouldn't it be great if military physicians could retire or separate and set up a practice that preferentially (or even exclusively!) took care of active duty & retired persons and their dependents? I bet a lot of physicians would like that.

I think your ire would be better directed at the persons who have set Tricare reimbursement rates so low that it's not possible to keep the lights on, the rent paid, the receptionist paid, the insurance premiums paid, the exam room stocked, etc etc etc, when every Tricare patient seen is a loss. Not the physicians who choose to donate a little of their time, instead of a lot of their time.

 

[militaryPHYS]

Lets all make sure we are clear on who and what we are defending. Any "character issues", "patriotism" discussion, "ethics of veterans" in which you all claim I am insulting was never directly stated by me and came from others via counter-discussion. You all know I would never question or discuss that kind of stuff. I cannot help it if you choose to personally take my disagreements with a topic as an attack on your person.

I lean right on most issues. I love capitalism and I appreciate the ability for us to choose how we make a living. As a physician though, I do not agree with the ability for us to choose who and what we see. To specifically decide that a specific subset of the population can't be seen I'm not sure I will ever understand. So I'm sorry if this is a point of contention. Obviously, Tricare is a specific subset of the population which we all care a ton about. I have strong feelings about it and I felt it was a place I needed to voice it. But don't take my disagreement with your practice's decisions on who to see as an attack on your clinical practice or military service just to capitalize on your counter arguments. And please don't say things like "keep the lights on" to also bolster your counter discussion when many of you have voiced very specifically on your salary increase since leaving the service and practice's annual revenue.

My issue IS with the government and the poor reimbursement which Tricare pays out. I'm working via the channels I have to get updates on the issue and affect change. But when people claim they are advocating for Tricare beneficiaries by refusing to see them whilst doing nothing else, then my issue is also there.

I've tried hard to avoid these rabbit hole discussions and will continue to in the future. Please feel free to have this discussion reviewed if you have issue with me being a moderator. Claiming that I am attacking veterans is a new low.

 

[deleted480308]

Lets all make sure we are clear on who and what we are defending. Any "character issues", "patriotism" discussion, "ethics of veterans" in which you all claim I am insulting was never directly stated by me and came from others via counter-discussion. You all know I would never question or discuss that kind of stuff. I cannot help it if you choose to personally take my disagreements with a topic as an attack on your person.

I lean right on most issues. I love capitalism and I appreciate the ability for us to choose how we make a living. As a physician though, I do not agree with the ability for us to choose who and what we see. To specifically decide that a specific subset of the population can't be seen I'm not sure I will ever understand. So I'm sorry if this is a point of contention. Obviously, Tricare is a specific subset of the population which we all care a ton about. I have strong feelings about it and I felt it was a place I needed to voice it. But don't take my disagreement with your practice's decisions on who to see as an attack on your clinical practice or military service just to capitalize on your counter arguments. And please don't say things like "keep the lights on" to also bolster your counter discussion when many of you have voiced very specifically on your salary increase since leaving the service and practice's annual revenue.

My issue IS with the government and the poor reimbursement which Tricare pays out. I'm working via the channels I have to get updates on the issue and affect change. But when people claim they are advocating for Tricare beneficiaries by refusing to see them whilst doing nothing else, then my issue is also there.

I've tried hard to avoid these rabbit hole discussions and will continue to in the future. Please feel free to have this discussion reviewed if you have issue with me being a moderator. Claiming that I am attacking veterans is a new low.

You don’t agree with a doctor’s right to limit who they see based on their ability to actually pay the expected rate? Do you think doctors should be forced to take tricare?

 

[Chonal Atresia]

Lets all make sure we are clear on who and what we are defending. Any "character issues", "patriotism" discussion, "ethics of veterans" in which you all claim I am insulting was never directly stated by me and came from others via counter-discussion. You all know I would never question or discuss that kind of stuff. I cannot help it if you choose to personally take my disagreements with a topic as an attack on your person.

I lean right on most issues. I love capitalism and I appreciate the ability for us to choose how we make a living. As a physician though, I do not agree with the ability for us to choose who and what we see. To specifically decide that a specific subset of the population can't be seen I'm not sure I will ever understand. So I'm sorry if this is a point of contention. Obviously, Tricare is a specific subset of the population which we all care a ton about. I have strong feelings about it and I felt it was a place I needed to voice it. But don't take my disagreement with your practice's decisions on who to see as an attack on your clinical practice or military service just to capitalize on your counter arguments. And please don't say things like "keep the lights on" to also bolster your counter discussion when many of you have voiced very specifically on your salary increase since leaving the service and practice's annual revenue.

My issue IS with the government and the poor reimbursement which Tricare pays out. I'm working via the channels I have to get updates on the issue and affect change. But when people claim they are advocating for Tricare beneficiaries by refusing to see them whilst doing nothing else, then my issue is also there.

I've tried hard to avoid these rabbit hole discussions and will continue to in the future. Please feel free to have this discussion reviewed if you have issue with me being a moderator. Claiming that I am attacking veterans is a new low.

You “believe” in capitalism but think physicians should be forced to see everything/anything that walks through the door, regardless of type of insurance/ability to pay? That sounds like the opposite of capitalism to me but I didn’t major in political science.

Medicine is a business and having this ideal that you shouldn’t have control over what you see/treat is naive.

BTW, I do offer limited charity care. Also, every time I take call and see someone without insurance that is also charity care. I don’t get paid for call.

 

[militaryPHYS]

It is counter to my beliefs in capitalism. I understand that. But that is because I think that medicine is more than just business. You can make a business out of it, but at its core medicine is not based on turning a profit. It is to care for others.

Obviously you go under if you only care for those who can’t pay, so I agree there has to be a balance. I just think that flat out refusal to see a certain sub population of our society is not the right balance. Just my opinion.

 

[deleted480308]

It is counter to my beliefs in capitalism. I understand that. But that is because I think that medicine is more than just business. You can make a business out of it, but at its core medicine is not based on turning a profit. It is to care for others.

Obviously you go under if you only care for those who can’t pay, so I agree there has to be a balance. I just think that flat out refusal to see a certain sub population of our society is not the right balance. Just my opinion.

Is your opinion everyone should voluntarily take some losses on some patients or should it be forced?