We all know that California has some of the lowest contracts in the country and then there's the "extra" effort that goes along...5 years of records to pay the physician for a $110.00 office visit? BD
We were spending inordinate amounts of time and resources on things that have nothing to do with the quality of patient care," said gynecologist Felice Gersh, medical director of the four-doctor practice. "I would be more than happy to be a member of all the health plans if they paid me reasonably and quickly." For instance, Gersh received a letter in August from Nationwide Health Plans over a $110 charge for an office visit. The insurer refused to process the claim unless Gersh sent five years' worth of patient records including chart notes, pharmacy records and lab/X-ray results.
Some Orange County specialists dropped the Blue Cross PPO over the summer after cuts were made in payments for surgeries and cancer care. Other doctors have opened concierge practices that allow them to be less dependent on insurance for income because they charge patients an annual retainer.
Former Gersh patient Paula Wilson said the change has been a nightmare. In July, Gersh performed Wilson's hysterectomy. She's been experiencing abdominal pain but says she can't afford to see Gersh for testing because that would trigger an out-of-network deductible in the thousands of dollars. Wilson is seeing other physicians within her United Health network.
"It is pretty risky," Denny said. "It's a major paradigm shift to terminate all your insurance. I think we'll see more of it, but it's only the beginning."
Hat Tip: Kevin, MD
I manage a solo family practice in Dublin, OH and we are days away from shutting our doors. The doctor filed for personal bankruptcy as we struggle to plow through the complex healthcare reimbursement matrix. Our AR is $174,000, about $115,000 after contractual discounts. Our reimbursement projection is 66% because of our high number of Workers’ Compensation, which pays 80-89%. The majority of these claims, generated since October 2007, are still outstanding.
ReplyDeleteWe're lucky to see 20k of the 40k-50k a month we're owed, after contractual reduction. (Expenses total 25-30k/month, 7k+/month for rent alone.) It's not just lack of reimbursement, but improper reimbursement. Insurance companies expect us to pay for our patients' healthcare. For example the Meningitis vaccine costs $85 from the manufacturer; $115 from other suppliers, NOT including our cost for administration, as the Dr. and I are currently the only employees working for free. Tricare is our highest payer for the vaccine so far at $46, or 40-54% of our cost.
We don't have time to address appeals on all of our improperly adjudicated claims; buried by constantly changing rules and current claim tracking. Ironically, we receive letters stating the check is in the mail. We try to pay our bills with these letters, but we're still forced to pay 10-30% interest when we're late; offset by the $0.01-$0.31 paid in interest by insurance companies for claims paid late.
The practice has ninety days to 12 months, depending on the company, to force insurers to accept claims or we don’t get paid. Insurance companies have two years, according to our provider reps, to take back reimbursement of previous claims from money owed on current claims. I’ve even had to fight for money taken back that was never received.
“Take-backs”, an insurance company term, are a result of insurers giving patients credit, paying the claim or not, then taking back the alleged reimbursement after two years when an audit proves the patient or their employer allegedly never paid for their benefits. Thus, we're not the creditor but we’re forced to be the collector. The insurance company mantra "eligibility is not a guarantee of benefits" means, see your doctor and if we refuse payment or take benefits away after the fact, it's their fault.
This month we're forced to cease scheduling government healthcare recipients; except Tricare, and anyone who can't pay upfront, pending reimbursement. Tricare, United Healthcare, and Aetna help with real-time, online adjudication and direct deposit, but it may be too little too late. Like Shel Silverstein's The Giving Tree, we have nothing left to give.
I have taken your comments here and created a new post for tomorrow so hopefully more will be able to read. Thank you for the comments and taking the time to share. Hopefully other readers will be able to benefit by reading as the patient usually has no idea as to what goes on in the administrative side of a practice this day until something in the system fails them personally.
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