Reimbursement

[TWR]

Does anyone know the amount of money paid for office visits in primary care? This practice takes everything out there. Specifically 99213, 14,15. Even an average would be helpful. I know there are variables but for example, seeing 20-25 patients a day = $$$$ Thanks for any help.

[ventana]

varies by location

CMS has a search tool that will give you the Medicare rates

 

Commercial insurance is pretty much always higher

 

https://www.cms.gov/apps/physician-fee-schedule/overview.aspx

 

 

 

Their is also data now available for how much any provider collected from medicare in past years - this is HIGHLY skewed as many/most of the places still bill for PA work under the MD/DO

[jmj11]

Does anyone know the amount of money paid for office visits in primary care? This practice takes everything out there. Specifically 99213, 14,15. Even an average would be helpful. I know there are variables but for example, seeing 20-25 patients a day = $$$$ Thanks for any help.

This is a complicated number. It depends on many factors, most of all (with private insurers) the contracted rate. That will vary from practice to practice.  Before I started my practice, I spent many hours on these numbers. I reviewed the payment rates for a variety of local practices (thanks to nice office managers who would share that information with me).  But here is where I was blind-sided a bit and I will give you caution.

 

So, if you had hard numbers, say 99214 is paid at $105. So, you figure, If I saw 25 patients at this rate, I will get paid $2,625. So you submit the claims for that day's 25 patients.  Then two weeks later you get a couple of checks for $105.  Then a week later you get another check for $105, and four letters telling you the insurance is paying $0 for those visits. They will then attach codes that suggest that patient # 3 was "not in their system" (even though your practice did a check to make sure they were insured at the time of the services). Two of the letters say that YOU are not in their system. You double check and you are contracted with the insurance company and it appears you are in their system.

 

So, you get you biller on the phone to track these down. She is on hold for 90 minutes listening to Barry Manilow songs played on a Hammond organ, with the first insurer and ends up with no clear answer why they consider the patients was not enrolled at the time of the service, but to call back next week and they will see if they can figure out why their computer rejected that claim.

 

In the meantime three more letters come that say they are paying $0 for a variety of reasons (none which make any sense). Finally you receive another payment of $105 so now you are up to $420 for that day's work and now and it is a month later. You now have seven of the 25 patients accounted for, 4 which paid. Now your biller, whom you are paying $20/hour is on the phone 8 hours per day trying to track down the remaining unpaid claims for that first day.

 

After another month four more pay at $105. Six more pay $0 for a variety or reasons, none which makes any sense. Your biller has now spent more 4 hours ($80 you paid for her time) to resolve one claim. It was a typo at the insurance company (most errors are at the insurance company). Actually, the patient was enrolled and they will pay you $80 (not the $105 that you contracted for and no explanation is made as to why they are only paying you $80). So that patient visit was awash.

 

Next you get  a letter from the first insurance company that paid you, saying you MUST pay them back the $105  within two weeks because they "over paid" you for that visit, according to a company they have hired to look for over-paid claims. The patient had a different primary insurance that they forgot to tell you about at the time of the visit.

 

SIx months later, you now have $1400 payments for that first day, that you expected to be $2625. Also you have paid your biller $550 for the hours she had to spend on the phone trying to get you paid for the rejected claims from that one day. In the end, most of the rejected claims were due to insurance company mistakes or the patient giving your wrong information. Sometimes if is for very complex reasons, such as a very particular insured group number require prior authorization to see you (and there was no way to know that) so now, that you have seen them without the prior authr, they will pay you nothing. The unpaid claims are then put on patient accounts. It is a fact, if you do not collect what the patient owes at the time of service you have about a 40% chance of ever getting a dime from them.

 

This is the harsh realities of doing business with insurance companies. I did not foresee this as clearly as I should have. I punched my numbers are you are trying to do and came up with a much higher expected collections. I went through 5 billers, thinking they were the problem, but it is systemwide.

 

Software/billing companies will claim that they can get you 97% of the money owed you, but they write off all the ones the insurance company says that they will not pay due to error codes (again, most of these errors are on the insurance company's side). Don't buy the software because it will cost you a lot and the collections will probably be worst. 

[jmj11]

Sorry about the typos above (like hars should be harsh etc.) It is hard to type with one hand and drink coffee with the other.

[TWR]

when I owned my own practice in NYC in the early 90's through 2000 it was a Medicaid practice where you swiped there ID and it said you were eligible or not.  I did have a billing company but Medicaid was steady with their payments every week.  No major issues.

[jmj11]

The problem with insurance company impedance was a problem that has existed for some time but has become a huge problem since the ACA, being tied to their fear of losing money. The amount of rejections prior auths and other paper work (and mistakes on their side) have skyrocketed since 2009.

[ventana]

I recently was asked by an insurance company to do a PA for Bactrim DS..... WTH??????????