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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.
Like I asked before - if you would be so kind as to tell us the area you specialize in?
Also - the "insurance only" stuff that I remember dates back at least 10-20 years. Don't know if it was illegal back then. Haven't seen it for a long long time. 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%).
Actually, what Medicare allows Mayo - as a nonparticipating Medicare provider - is 115% of 95% of the Medicare-allowed charge
Quote:
They can charge you more than the Medicare-approved amount, but there's a limit called "the limiting charge." The provider can only charge you up to 15% over the amount that non-participating providers are paid. Non-participating providers are paid 95% of the fee schedule amount.
Paid as follows:
$ 76.00 - Medicare pays 80% of $95
...33.25 - Patient (or Medigap) pays
Quote:
Originally Posted by toofache32
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%. T
In reality - Medicare has participating providers who accept assignment/payment in full from Medicare. Nonparticipating providers have the option to charge the 15% limiting fee - but are not required to.
Quote:
Non-participating providers haven't signed an agreement to accept assignment for all Medicare-covered services, but they can still choose to accept assignment for individual services. These providers are called "non-participating."
In the end, the net excess to the provider is 9.25%, not 15%. Not a big motivation, at all, to accept Medicare - which explains Robyn's remarks on why Mayo in FL won't accept "new" Medicare patients (unless they are concierge, I would imagine).
Last edited by Ariadne22; 11-25-2015 at 05:08 PM..
I have knowledge of the current procedures as a Medicare provider. Although I am kicking Medicare to the curb in my practice on January 1st, 2016.
I wish it was as simple as just submitting a code. We have to submit the code with "correct" modifiers, and with a diagnosis that will link to the code. But they WILL NOT tell us the "correct" way to do it. For example, I had a claim denied yesterday for a 38724 (modified radical neck dissection) that I submitted with a -59 modifier indicating a separate procedure from the 41130 (hemi-glossectomy) I also did. I have learned that without the -59 modifier Medicare will deny it and tell me that I should have used 41135 (glossectomy with radical neck dissection) because it includes the neck dissection. But they are incorrect about that because 41135 includes a radical neck dissection (38720), but not a modified radical neck dissection. For the first time in years, they found a new way to deny it. They sent back a denial letter stating the 38724 code requires an "anatomical modifier" even though they have never required it before. And there is no database that lists which of the 60+ modifiers are required in any situation. So now I have to pay my staff again to re-submit the claim again with a 38724-59,LT series of modifiers to see if that will work. We called them to ask and, as expected, they said "we cannot tell you how to code." I hope the one I submitted is the one they are looking for. It took me 2 months to find out the first time and now it will take another 2 months to see if I got it right. Who else here likes to work and not get paid for 4 months?
I have learned that the general public really thinks we just submit a bill to the insurance company that says "broken arm, fixed it" and we get paid. Every dollar is a fight. Remember...insurance companies are not in the business of paying claims, they are in the business of NOT paying claims.
Yes I have always submitted this code using those guidelines. But now Medicare telling me it's wrong in this case, even though the same code/modifier was right every other time I have done the same surgery. When asked for the correct way, they respond "we will not tell you how to code." Keep in mind that each insurance plan has their own arbitrary rules and this is just one example code out of hundreds that I use. This is purposefully cryptic and confusing as a way to decrease payments to doctors with "gotchas". When they create more and more hoops to jump through, many like me will simply stop jumping because it's not worth it. This type of surgery is not a money maker (quite the opposite actually) and I do it because I enjoy this type of surgery and helping these patients. In the end, it's the patients that suffer when they have trouble finding a doctor that will treat them because of their insurance company's behavior.
Last edited by toofache32; 11-26-2015 at 07:57 AM..
Yes I have always submitted this code using those guidelines. But now Medicare telling me it's wrong in this case, even though the same code/modifier was right every other time I have done the same surgery. When asked for the correct way, they respond "we will not tell you how to code." Keep in mind that each insurance plan has their own arbitrary rules and this is just one example code out of hundreds that I use. This is purposefully cryptic and confusing as a way to decrease payments to doctors with "gotchas". When they create more and more hoops to jump through, many like me will simply stop jumping because it's not worth it. This type of surgery is not a money maker (quite the opposite actually) and I do it because I enjoy this type of surgery and helping these patients. In the end, it's the patients that suffer when they have trouble finding a doctor that will treat them because of their insurance company's behavior.
I agree. Insurance companies, hospitals, and pharmaceuticals must be reviewed for extreme cost inflation and general practices. Hospital administration costs must be reviewed heavily as well.
When I had a biopsy for micro calcifications, I questioned a $100 charge. It was for a band-aid with bacitracin on it. Good to know, next time I'll bring my own. This was 12 years ago.
Here's an interesting article that lays out who is getting paid what. And it appears some doctors in Wisconsin have had enough and are kicking back at the hospitals, health insurance companies, and pharmaceuticals. I'm sure that there are others out there as well!
...In the end, the net excess to the provider is 9.25%, not 15%. Not a big motivation, at all, to accept Medicare - which explains Robyn's remarks on why Mayo in FL won't accept "new" Medicare patients (unless they are concierge, I would imagine).
Thanks for the detailed explanation of how this works. Will take your word that it works this way (I don't have a clue). In the end - all I care about is keeping my current doctors - and having access to good ones I may need in the future. And I am quite powerless as an individual to make sure this happens.
FWIW - Mayo in Florida does in general accept new Medicare patients in all areas except primary care. That's where the concierge practice comes in. Also - there are certain departments and sub-specialists who are booked up for years/not taking any new patients - Medicare or not. Someone told me the migraine clinic is like that - but I don't have any personal experience with it or any other departments/sub-specialists like this. I suppose it is possible that if I ever needed care in one of these areas - that participation in the concierge program might give me a "leg up". Don't know. Robyn
I am an oral & maxillofacial surgeon with a heavy focus in head & neck cancer surgery.
I guess - judging from your name here - that you are on the "dentist" side of this - not the "doctor" side - right? I've had experiences with both (although only with my late FIL on the doctor side - he had angiosarcoma - a horrible aggressive cancer - on his head). The doctor my FIL saw at Mayo took Medicare. Our family oral surgeon dropped out of Medicare about 5 years ago (it was a small part of his one man practice and he couldn't stand dealing with Medicare either). And I doubt he's unique in this neck of the woods. Perhaps it's an issue of being in a big outfit where you have a large billing department versus being in a small outfit?
FWIW - I can understand your billing/coding frustrations. We as consumers/patients have them too. For example - my husband had endocarditis years ago - has a small hole in his heart valve - and needs a yearly echo to make sure he's ok. Medicare won't pay for a yearly echo for everyone. And even Mayo has trouble every year getting the billing code right for his echo.
Of course - ICD-10 just makes it harder for everyone:
Here's an interesting article that lays out who is getting paid what. And it appears some doctors in Wisconsin have had enough and are kicking back at the hospitals, health insurance companies, and pharmaceuticals. I'm sure that there are others out there as well!
Another thing to consider is that doctors can earn as much or more not being doctors who treat patients. In easier jobs. When it became obvious to my brother the doctor that he couldn't retire before he was 70 - he quit clinical practice (in his 50's) and went to work for a big pharma company. Not only are the hours better - but he has lots of corporate benefits (and he gets to travel a lot for the company - which he enjoys). Also - he never has to worry about billing codes again. Robyn
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