Medicare approved $1000 bill for just stepping into ER. No wonder our healthcare system is bankrupt (oral, Wisconsin)
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P.S. Sometimes it is a matter not of accepting an insurance plan - but of accepting a particular PPO. Before I went on Medicare - I was insured by the Florida high risk pool. Which had contracted with a national PPO (which wasn't an insurance company). Called Beech Street:
So the issue for me was whether a provider had a contract with this particular PPO. I think this kind of thing still exists - probably for the most part when it comes to large self-insured companies that have contracts with outfits like this.
The way it works from my POV as a customer is that providers are free to accept or decline patients from various insurance company plans. For example - Mayo Clinic here - where I get most of my health care - accepts many insurance plans from various insurance companies - but not Medicare Advantage HMO plans from the same companies:
I suppose an insurance company could require a provider to accept all of its plans/patients - but the insurance companies apparently don't do that.
When it comes to regular Medicare - not Medicare Advantage - there are 3 options. I am familiar with the first 2. "Accepting" Medicare. And not "accepting Medicare" but accepting Medicare patients. The first means that a doctor will take what Medicare/Medigap policies pay in full payment. I have 2 doctors outside the Mayo system who do that.
The second - which is what Mayo does when it comes to Part B Medicare expenses (not Part A) - means that the doctor will accept Medicare patients but patients are responsible for their own bills. What this means operationally is that you go to Mayo. Mayo sends you a bill for its services. Which you are responsible for paying. Mayo does notify Medicare and your Medigap insurance company of the visit(s)/charges(s). And you get the money to pay the bill from Medicare/your Medigap carrier (parenthetically - this is nice way to rack up miles/points on your credit card ). By operating in this fashion - a provider is allowed to charge you 15% more than normal Medicare rates (don't ask me why - nothing logical about it IMO). Which Mayo does. This extra 15% may or may not be covered by your Medigap policy (it is covered under the Medigap policies my husband and I have).
The third is just opting out of the Medicare program altogether - having nothing to do with it. In that case - you can see Medicare patients - charge them whatever you want - and they are responsible for paying you (and they won't get any help from Medicare for the most part either).
Note that this is just a general outline. Although I am a lawyer - I am not a health care lawyer. And I would recommend consulting with a lawyer - or perhaps going to some CME courses/getting CME materials - to make sure that I was doing everything properly (regardless of what I decided to do). Robyn
This is what my practice has already decided to do. Letter already sent in. Good riddance.
This is what my practice has already decided to do. Letter already sent in. Good riddance.
If you would be so polite to respond - what is your specialty area?
I had a pretty interesting discussing with my Doctor Plastic Surgeon this week. His practice of course is mostly pay out of your own pocket - for everyone - for cosmetic work. Insurance doesn't enter the picture. But I have stuff that Medicare actually pays for. Large - often infected - sebaceous cysts (long personal/family history of that). And I asked my Doctor Plastic Surgeon why he took me and my Medicare. And he said - because he would be on Medicare one day too (he's in his 50's now) - he hoped that his doctors wouldn't abandon him just because he got old - and he didn't care to abandon his older patients now.
Perhaps it is easier to live with Medicare patients when the majority of your patients aren't Medicare patients? I know that we can't get primary here at Mayo as Medicare patients unless we join its concierge practice. I guess there's a difference between doing 5-10% Medicare and 65% Medicare. A doctor can make a living doing the former - not the latter. Robyn
If you would be so polite to respond - what is your specialty area?
I had a pretty interesting discussing with my Doctor Plastic Surgeon this week. His practice of course is mostly pay out of your own pocket - for everyone - for cosmetic work. Insurance doesn't enter the picture. But I have stuff that Medicare actually pays for. Large - often infected - sebaceous cysts (long personal/family history of that). And I asked my Doctor Plastic Surgeon why he took me and my Medicare. And he said - because he would be on Medicare one day too (he's in his 50's now) - he hoped that his doctors wouldn't abandon him just because he got old - and he didn't care to abandon his older patients now.
Perhaps it is easier to live with Medicare patients when the majority of your patients aren't Medicare patients? I know that we can't get primary here at Mayo as Medicare patients unless we join its concierge practice. I guess there's a difference between doing 5-10% Medicare and 65% Medicare. A doctor can make a living doing the former - not the latter. Robyn
Perfect examples of a doctor that is only in it for the money vs a doctor that is in it to care for his patients.
I reckon he and and his partners earn at least $500k/year or more.
IOW - they can afford a few Medicare "charity cases" like me (although some doctors in their position won't take Medicare charity cases like me).
The tougher cases are those where the doctors are in a specialty area where reimbursement levels are a heck of a lot lower - like primary care. BTW - I consider primary care to be a specialty area when my PCP is a board certified internist - not some PA at Walgreen's.
When our last PCP closed her practice - and went to work for a big corporation - the only PCP doctors we could find who would "feed us" into the Mayo system - where we get all of our secondary and tertiary care - were Mayo PCPs in the concierge practice there. Fee for that was recently increased from $8k/year for a couple to $10k. I guess I could make do in the Baptist or St. Vincent's health care systems here. They are probably both ok (although probably not as good as Mayo in the more specialized areas). And also - being Jewish - I don't care to go to hospitals with big crosses on top and all over the place (that is probably just a "Jewish thing").
We still have 2 doctors outside Mayo. Our family dermatologist who does our routine skin cancer screenings (she's a Mayo "graduate") and a doc at Baptist who cleans the wax out of ears every year or two (he "accepts" Medicare). But otherwise - we get everything else at Mayo. Robyn
If you would be so polite to respond - what is your specialty area?
I had a pretty interesting discussing with my Doctor Plastic Surgeon this week. His practice of course is mostly pay out of your own pocket - for everyone - for cosmetic work. Insurance doesn't enter the picture. But I have stuff that Medicare actually pays for. Large - often infected - sebaceous cysts (long personal/family history of that). And I asked my Doctor Plastic Surgeon why he took me and my Medicare. And he said - because he would be on Medicare one day too (he's in his 50's now) - he hoped that his doctors wouldn't abandon him just because he got old - and he didn't care to abandon his older patients now.
Perhaps it is easier to live with Medicare patients when the majority of your patients aren't Medicare patients? I know that we can't get primary here at Mayo as Medicare patients unless we join its concierge practice. I guess there's a difference between doing 5-10% Medicare and 65% Medicare. A doctor can make a living doing the former - not the latter. Robyn
Robyn, you certainly know my story. However, you might find this information useful. I've seen a lot of different things in my community, close up.
The oncologist who treated my father had an old group of patients that were largely Medicare patients. During the last stages of my father's disease, I got to know him pretty well. I asked him about his practice because he seemed very busy and his waiting room was always full. He told me that the way to function with Medicare was to fill up your appointment schedule and employ top notch collections people. He claimed if he didn't do that his practice wouldn't be profitable and the reimbursement rate for Medicare was, in his words, "downright terrible".
The situation with plastic surgeons is an unusual one indeed. Most plastic surgeons I've known derive the majority of their income doing breast augmentation procedures. What was a bit distressing to me is exactly how popular this surgery is and the charges for it. Doctor M. was a well known plastic surgeon in my community who has since retired. I used to send clients with scars to him for an examination and report. So, occasionally we would talk. Dr. M claimed he did two to three breast augmentation procedures in his office--I wonder if since than they would have to be done in an outpatient surgical center--every morning before noon. He admitted billing about $2,000 to $3,000 per procedure and gloated about how happy his patients were to pay and how he never had the stress of billing insurers. He saved afternoons for doing other plastic surgery work and he clearly viewed the afternoons as simply "surplus" after he made his real money in the mornings.
My FIL practiced orthopedic surgery for many years before cancer forced him to retire. He died some years ago. However, one day he gave me a memorable lecture on "the economics of medicine". He explained what was profitable and was not. He said MediCal (California's equivalent of Medicaid) reimbursed so badly he lost money every time he saw a patient. Worker's compensation was better, but full of arbitrary rules and very paper intensive work. Medicare was better than the first two, but he claimed only a high volume practice could make money from Medicare. Only private health insurance offered good reimbursement and he basically ran his practice off checks from Kaiser and other health insurance companies. I did note privately though that the guy did very well based on the lifestyle that my wife describes as a child. The information I obtained from is dated, but I am lead to believe it is still roughly accurate.
Perfect examples of a doctor that is only in it for the money vs a doctor that is in it to care for his patients.
I used to think that way also before I became a business owner and saw the reality. You only have to take out a loan to meet payroll once before you wake up. When Medicare or anyone doesn't pay me, I still pay my employees and pay the light bill. We all go to work every day for the same reason.
Robyn, you certainly know my story. However, you might find this information useful. I've seen a lot of different things in my community, close up.
The oncologist who treated my father had an old group of patients that were largely Medicare patients. During the last stages of my father's disease, I got to know him pretty well. I asked him about his practice because he seemed very busy and his waiting room was always full. He told me that the way to function with Medicare was to fill up your appointment schedule and employ top notch collections people. He claimed if he didn't do that his practice wouldn't be profitable and the reimbursement rate for Medicare was, in his words, "downright terrible".
The situation with plastic surgeons is an unusual one indeed. Most plastic surgeons I've known derive the majority of their income doing breast augmentation procedures. What was a bit distressing to me is exactly how popular this surgery is and the charges for it. Doctor M. was a well known plastic surgeon in my community who has since retired. I used to send clients with scars to him for an examination and report. So, occasionally we would talk. Dr. M claimed he did two to three breast augmentation procedures in his office--I wonder if since than they would have to be done in an outpatient surgical center--every morning before noon. He admitted billing about $2,000 to $3,000 per procedure and gloated about how happy his patients were to pay and how he never had the stress of billing insurers. He saved afternoons for doing other plastic surgery work and he clearly viewed the afternoons as simply "surplus" after he made his real money in the mornings.
My FIL practiced orthopedic surgery for many years before cancer forced him to retire. He died some years ago. However, one day he gave me a memorable lecture on "the economics of medicine". He explained what was profitable and was not. He said MediCal (California's equivalent of Medicaid) reimbursed so badly he lost money every time he saw a patient. Worker's compensation was better, but full of arbitrary rules and very paper intensive work. Medicare was better than the first two, but he claimed only a high volume practice could make money from Medicare. Only private health insurance offered good reimbursement and he basically ran his practice off checks from Kaiser and other health insurance companies. I did note privately though that the guy did very well based on the lifestyle that my wife describes as a child. The information I obtained from is dated, but I am lead to believe it is still roughly accurate.
I think your "dated information" is probably still correct for the most part. In terms of what pays best. Although reimbursement from all sources is probably worse than it used to be.
The area which has probably changed the most is Medicare. Especially in the area of primary care. Mayo Clinic here does have a non-concierge primary care department. It was closed to new patients on Medicare when its Medicare patient population approached 2/3 of all patients. Because it was a big money-loser. The goal is to get the Medicare population down to 1/3 or less (by attrition). At which point - the department will be profitable again (assuming Medicare reimbursement isn't reduced even more).
Best I can figure out with Mayo - it makes money on Medicare patients largely by doing a lot of tests and procedures (surgeries too). Which Medicare still reimburses at somewhat reasonable levels. To explain a little more. It's a big place. And say it has a CT machine (I suspect it has more than one). Well I know that these CT machines run almost continuously for probably more than 12 hours a day (from early morning to early evening). And there's a fixed overhead to running a machine. So say regular patients use the machine 70-80% of the time. Well - rather than let the machine "sit empty" - Mayo will use Medicare patients to fill up the remaining time slots. Because Medicare pays at least enough to cover the overhead. It's kind of like an airplane flying with empty seats or a golf course having empty tee times. There is a minimum discounted price at which the airline or golf club can sell the seat or the tee time and still wind up better off than letting them go empty.
Now one way Mayo makes this work for Medicare patients is by using the most expensive Medicare billing model allowed by law - i.e., "not accepting Medicare". Which means it can (and does) bill 115% of what Medicare usually allows. Directly to the patient. I know that in the past - some doctors would accept the 80% that Medicare pays - and "eat the rest". Don't know any doctors who do that today. But few if any use the billing model that allows the extra 15% charge. In any event - Medicare patients who use Mayo need traditional Medicare with a good Medigap policy (and some even cover that extra 15%).
Note that Mayo doesn't accept Medicaid or Medicare HMO patients (except in some very rare cases that are negotiated in advance). And it doesn't do OB or pediatrics (2 relatively low paid specialties). At least in Florida (and probably Arizona). The situation is different in Minnesota - because Mayo there is in a small somewhat isolated city where it is pretty much the only game in town. Note also that Mayo has a substantial number of patients who don't live here. Whether they're executives with "gold plated" insurance getting "executive physicals". People with money from other countries whose medical care isn't as good as ours. People from other parts of the US who need tertiary care that isn't available where they live (especially organ transplants - Mayo does a ton of transplants - and the organ waiting list here is much shorter than in most parts of the US). So - overall - Mayo probably has a better "patient base" in terms of what people are willing/able to pay for medical care than most places. My husband and I are very happy with Mayo - and we hope it never "kicks us out".
When it comes to plastic surgery here - I don't know the breakdown of various cosmetic procedures. But one package that seems to be very popular is the "new mommy package" - which is a combination of things like a tummy tuck - liposuction - and some form of breast modification (making them bigger/smaller/perkier whatever). There's also a lot of work done with Botox and similar. The people in our community are pretty young - and most of the women (and men) I see in my doctor's waiting room seem to be 40 or younger. Most of these surgeries - even long complicated ones under general anesthesia - are done in the out-patient surgical suites in my doctor's "office". To keep costs down. This wouldn't be my cup of tea (I am not at all fond of general anesthesia anywhere) - and there are disputes in the medical establishment from time to time about doing these surgeries outside hospitals. But that seems to be the way things are done these days. Robyn
Now one way Mayo makes this work for Medicare patients is by using the most expensive Medicare billing model allowed by law - i.e., "not accepting Medicare". Which means it can (and does) bill 115% of what Medicare usually allows. Directly to the patient. I know that in the past - some doctors would accept the 80% that Medicare pays - and "eat the rest". Don't know any doctors who do that today. But few if any use the billing model that allows the extra 15% charge. In any event - Medicare patients who use Mayo need traditional Medicare with a good Medigap policy (and some even cover that extra 15%).
For some reason, Medicare has 3 options to provide care to Medicare patients which I don't completely understand. The "middle" option allows the extra 15%. The most expensive model is to have nothing to do whatsoever with Medicare, which is what I will be doing. For the procedures I do, my fees are probably around 3-4x Medicare fees off the top of my head.
Doctors cannot accept "insurance only" as this is fraud and leads to increased utilization rates of insurance. The insurance companies WILL prosecute for this.
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). By operating in this fashion - a provider is allowed to charge you 15% more than normal Medicare rates (don't ask me why - nothing logical about it IMO). Which Mayo does. This extra 15% may or may not be covered by your Medigap policy (it is covered under the Medigap policies my husband and I have).
