WHAT IS THE COST OF CARE?
I have of late been resubmitting claims for a surgeon who has been denied payment for one reason or another. Who knew the any insure that was not a CDHP had a deductible of $10,000? Or a procedure paid for at $5500 for 75% of all insurers is paid less than $1500 by another insurer. Don’t wonder why increasing numbers of physicians are leaving managed care; given that kind of disparity, it would be crazy not to.
No one actually knows what to charge for anything anymore. Medicare makes a determination based on a formula including geographic and market basket data, the cost of labor, and many other things, and their payment is supposed to be the cost of care plus a small percentage profit. Because of the many bills I review, I can see what they pay – and I don’t see how a provider could stay in business with such miserable compensation.
So if Medicare pays a provider $175, while insurers pay between $300-$450 and then the uninsured are charged $600-$700 all for the same procedure, certain calculations come into play: what is the mix of patients I must have to make my bottom line $X. Do I practice in an area of heavy managed care penetration and what insurers are they? What are their internal benchmarks I must meet? How many Medicare patients can I realistically afford to serve? If a patient comes to me with a point-of-service option, how do I know he/she can really afford to pay me if I balance bill them?
What does any of this have to do with good health care? Nothing.
Crossposted at http://www.signalhealth.com/commentary
No one actually knows what to charge for anything anymore. Medicare makes a determination based on a formula including geographic and market basket data, the cost of labor, and many other things, and their payment is supposed to be the cost of care plus a small percentage profit. Because of the many bills I review, I can see what they pay – and I don’t see how a provider could stay in business with such miserable compensation.
So if Medicare pays a provider $175, while insurers pay between $300-$450 and then the uninsured are charged $600-$700 all for the same procedure, certain calculations come into play: what is the mix of patients I must have to make my bottom line $X. Do I practice in an area of heavy managed care penetration and what insurers are they? What are their internal benchmarks I must meet? How many Medicare patients can I realistically afford to serve? If a patient comes to me with a point-of-service option, how do I know he/she can really afford to pay me if I balance bill them?
What does any of this have to do with good health care? Nothing.
Crossposted at http://www.signalhealth.com/commentary
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