Even before the FBI decided to raid my office and inform Medicare, directly or indirectly, that it didn't have to pay me for the patients I continued to see, the biggest frustration in solo practice was getting paid.
My billing staff and I have given up on trying to reach anyone who can tell us why Medicare hasn't been paying for my services. No one seems to know. But when was the last time you heard a government worker say, "I don't know what's going on"? Instead, we've heard a broad range of explanations for non-payment, none of which can be substantiated. There is no room for my defense. Medicare's defense against our questions is simply to ignore our calls and letters.
Not including efforts to understand the government's actions, my office spends 100 hours per week trying to get paid for the work we do. I have two full-time billing staff, who enter charges, post payments, and appeal non-payments. In addition, there are front office staff you spend part of their time calling insurance companies in advance, or trolling through their complicated websites to find out if a patient's plan covers care in our office.
Very often, the coverage is so complicated we have trouble explaining the exceptions and variable co-pays to patients. For example, a patient may have a $500 deductible, but it doesn't apply to a preventive visit. So the patient schedules a preventive visit, thinking "that's free," but then reports a list of worrisome symptoms. To figure out what the symptoms mean, I may recommend some tests.
For an x-ray, that same patient may need to pay 20% of the charge pre-set by the insurance company, but for an ultrasound, the patient may need to meet the full amount of the deductible before getting any insurance help. If labs are necessary, some might be covered, arbitrarily labeled as "routine," but others, such as a test for lupus or celiac disease, might not be covered. Some labs might be paid for only if the sample is sent to a specific lab, with whom the insurance company has negotiated a cut-rate--so if we want to get an immediate result with the same test in our office, we have to do it for free. It's not permissible for the patient to pay out-of-pocket for any tests unless they're non-covered or the money will be applied toward the deductible, and the tests are "pre-authorized." If I wish to do a skin surgery, I may have to get permission from the insurance company in advance, so it can't be done the same day. For some insurance companies, I only need to get permission after the first three, or five surgeries of the year. But the insurance company can't tell me if another doctor has already done surgeries this year, and the patient has met the maximum number of surgeries allowed...then I don't know whether I need an override or not.
The 100 hours of work applied toward collecting from insurance companies doesn't include the hours I spend each evening reviewing charges and chart documentation, as I have always done, to confirm that all services for which we are billing were actually provided, and the documentation proves it.
Medical Economics reports the following after reviewing data from a physician survey. "Primary care physicians are frustrated by a seemingly endless bureaucracy to collect the lowest rates in healthcare....The frustration for most physicians focuses on the day-to-day negotiation of care and the work involved just to get paid. The work involved to stay current with the throng of electronic filings and paperwork surrounding coding, billing, reimbursement, denials and collections is inordinate."
The medical clinics described in this report say that the majority of payments are received within 3 months, with Medicare taking 60 days to pay. But in my office, Medicare refuses to pay every claim, requiring copies of all office notes and procedures performed, before its agents will reconsider. We need more filing clerks to do all the copying for Medicare, and then we have to make a run to the post office every day to send out the paper proof. Then, one year later, we may receive payment. At least, that's the time-frame under which we're working now.
Would you wait a year to--maybe--get paid for your work? Sure, I would--if I knew the patient and had a sense of his or her dire circumstances. But not 100% of the time--I couldn't survive. And not for the government, not after what it's done to me.
No one thinks things are going to get better. I don't see a light at the end of the tunnel, not for me, and not for all the doctors so far lucky enough to have escaped the government's scrutiny and refusals to pay. Most of them are hiding out in gigantic medical conglomerates anyway. But I'd rather go back to hoeing potatoes.
My billing staff and I have given up on trying to reach anyone who can tell us why Medicare hasn't been paying for my services. No one seems to know. But when was the last time you heard a government worker say, "I don't know what's going on"? Instead, we've heard a broad range of explanations for non-payment, none of which can be substantiated. There is no room for my defense. Medicare's defense against our questions is simply to ignore our calls and letters.
Not including efforts to understand the government's actions, my office spends 100 hours per week trying to get paid for the work we do. I have two full-time billing staff, who enter charges, post payments, and appeal non-payments. In addition, there are front office staff you spend part of their time calling insurance companies in advance, or trolling through their complicated websites to find out if a patient's plan covers care in our office.
Very often, the coverage is so complicated we have trouble explaining the exceptions and variable co-pays to patients. For example, a patient may have a $500 deductible, but it doesn't apply to a preventive visit. So the patient schedules a preventive visit, thinking "that's free," but then reports a list of worrisome symptoms. To figure out what the symptoms mean, I may recommend some tests.
For an x-ray, that same patient may need to pay 20% of the charge pre-set by the insurance company, but for an ultrasound, the patient may need to meet the full amount of the deductible before getting any insurance help. If labs are necessary, some might be covered, arbitrarily labeled as "routine," but others, such as a test for lupus or celiac disease, might not be covered. Some labs might be paid for only if the sample is sent to a specific lab, with whom the insurance company has negotiated a cut-rate--so if we want to get an immediate result with the same test in our office, we have to do it for free. It's not permissible for the patient to pay out-of-pocket for any tests unless they're non-covered or the money will be applied toward the deductible, and the tests are "pre-authorized." If I wish to do a skin surgery, I may have to get permission from the insurance company in advance, so it can't be done the same day. For some insurance companies, I only need to get permission after the first three, or five surgeries of the year. But the insurance company can't tell me if another doctor has already done surgeries this year, and the patient has met the maximum number of surgeries allowed...then I don't know whether I need an override or not.
The 100 hours of work applied toward collecting from insurance companies doesn't include the hours I spend each evening reviewing charges and chart documentation, as I have always done, to confirm that all services for which we are billing were actually provided, and the documentation proves it.
Medical Economics reports the following after reviewing data from a physician survey. "Primary care physicians are frustrated by a seemingly endless bureaucracy to collect the lowest rates in healthcare....The frustration for most physicians focuses on the day-to-day negotiation of care and the work involved just to get paid. The work involved to stay current with the throng of electronic filings and paperwork surrounding coding, billing, reimbursement, denials and collections is inordinate."
The medical clinics described in this report say that the majority of payments are received within 3 months, with Medicare taking 60 days to pay. But in my office, Medicare refuses to pay every claim, requiring copies of all office notes and procedures performed, before its agents will reconsider. We need more filing clerks to do all the copying for Medicare, and then we have to make a run to the post office every day to send out the paper proof. Then, one year later, we may receive payment. At least, that's the time-frame under which we're working now.
Would you wait a year to--maybe--get paid for your work? Sure, I would--if I knew the patient and had a sense of his or her dire circumstances. But not 100% of the time--I couldn't survive. And not for the government, not after what it's done to me.
No one thinks things are going to get better. I don't see a light at the end of the tunnel, not for me, and not for all the doctors so far lucky enough to have escaped the government's scrutiny and refusals to pay. Most of them are hiding out in gigantic medical conglomerates anyway. But I'd rather go back to hoeing potatoes.
you arebright and cheerful and wonderfully caustic correctly. But hope you hve not gvien up.Are you a member of AAFP and your local AMA?
ReplyDeletehey have truly come round to workng helpfully.
John Bender MD, Ft collins colorado worked out a sytem of clnics working together as real medical Homes, made t work well, the ended up predient for a year of Colordo AAFP, helping spread the good word, got peanalties agqins local medicaid foks, Now has been President Colo Med Society n, going onto be a delegate to AMA, and his ideas are spreading. 10 years since the so called conservative (fearful idiots wh cant stand change) Colorad AMA group resolved to work hard and fast to get areal honest functioning system . The AHC hasbeengerrmandered ito futility.but even so better thanwehad before. ral plan-- No copays, no waiting, the payioff is in doin real real preventive by eduicated primary docs who get paid what they are worth instead of piecework. its an old argument that our GOP and the insne overrich bunch fight refelxivel. He WE GOOD DOCS CAN Overcome.