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    How did Medicare become the highest paying carrier?

    Editor’s Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by Carol Gibbons, RN, BSN, NHA, who is CEO of CJ Consulting, which specializes in healthcare revenue cycle management. The views expressed in these blogs are those of their respective contributors and do not represent the views of Medical Economics or UBM Medica.


    Recently, I was working on credentialing with a client who is starting a practice in South Texas. I was shocked when we started getting contract proposals from the carriers and most of the major carriers were all at 80% of the current Medicare rate. I have been very vocal about the rates carriers pay physicians and the resultant physician’s search for ancillary services to generate enough revenue to pay the bills.


    Further reading: GOP Obamacare replacement bill puts physicians, patients in charge


    A medical practice cannot survive on visit revenue alone without seeing an extraordinary number of patients every day. We see practices struggling financially that have high Medicare or Medicaid populations because of the complexity of their healthcare without appropriate reimbursement for managing these highly complex patients. The only way for practices to survive is to add equipment and/or staff to provide additional ancillary services, develop cash pay services in their practice or see so many patients that the provider has little time with the patient. 

    Without ancillary services, the physicians only have time to push more medications to solve health problems and little time to coach patients to lifestyle changes that could reduce the numbers of medications they are on. If they do add ancillary equipment to their practice, many times they over order studies to generate enough revenue to pay the increasing cost of running a practice.

    As a consultant, I vet best ancillary services every month for practices. There are so many people knocking on their door to sell them the next piece of equipment or weight loss product, the overwhelmed providers are calling consultants to vet these services. There is a direct correlation to the move toward ancillary services and the dramatic reduction in reimbursement to physicians to actually take care of patients over the past 10 years. Certainly, this ancillary tsunami adds cost to our healthcare system and does not always provide an outcome that actually improves patient care.


    In the news this week: Apple looking to expand healthcare presence


    We should not stop the use of ancillary services. We only need to analyze the use of ancillary services to determine if this allows the provider to spend more time with each patient and improve their overall health status. If the service is just to generate income and the time with each patient does not show health improvements, then that just adds cost to our healthcare system. I have found the practices that are the most successful in changing patient behavior through ancillary services are those that teach the entire staff to be “health coaches.”  Everyone has to be focused on improving health, not just medicating illnesses.

    I also get angry when I look at the year-end financials of the major carriers in comparison to the fees they are paying new physician practices. If you pay attention to recommendations from investment advisors, Humana, Aetna, United Health Care, Cigna, etc., are recommended to investors because the company stocks are paying good dividends and have an increasing stock value. This is good for their investors but happens at the expense of their providers and to the detriment of their customers. It has not resulted in an improvement in population health that could drive down the overall cost of healthcare in our country.

    Next: How do we fix this part of our healthcare system? 

    Carol Gibbons RN, BSN, NHA
    Carol Gibbons brings 30 years of nursing and management experience to CJ Consulting to assist healthcare businesses in revenue cycle ...


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    • [email protected]
      You state: "A medical practice cannot survive on visit revenue alone without seeing an extraordinary number of patients every day." That is not correct. When the cost/RVU of running a medical practice is 30-40% above the Medicare conversion rate, you cannot make up the revenue shortfall by increasing patient volume. You simply lose money on every single patient you see. It has been trending this way for the past 20 years. That's the big lie of Medicaid/Medicare for all or a single payer system; physicians eventually become civil-indentured servants of the system. Also, don't forget that we all become patients eventually and it's doubtful we'll like the care we give, or receive under such a system.
    • [email protected]
      Hello..,My Uncle and his Wife was diagnosed with silicosis disease and COPD disease December 2013, they were given several medications to ease their condition as My Uncle was told there was no cure for both diseases. their symptoms were mainly shortness of breath, cough and weight loss that continued for over 3 years progressively getting worse.i saw so many post online about perfect health herbal medicine,people saying they cure different kinds of deadly diseases like,Parkinson,COPD,IPF,Chronic pancreatitis,Hepatitis b,ALS,Herpes,and so many more, I decided to give the perfect health herbal medicine a try.so contacted them via their email perfecthealthherbalmedicine(AT)gmail(DOT)com,website www(DOT)perfecthealthherbal(DOT)weebly(DOT)com.so we purchased the herbal medicine,which was shipped to us,My uncle and his wife herbal medicine treatment took 35days in total to be cured. I would say a majority of my uncle and his wife symptoms dissapeared 20days after treatment began.they went for a follow up spirometry test and my doctor couldn’t believe they was the same husband and wife he saw the last time and My doctor confirmed their lungs were functioning better now 100%, Its unbelievable! I thank perfect health herbal medicine from the bottom of my heart for giving my uncle and his wife life back.
    • Anonymous
      The only way costs will go down is if there is a government exchange to compete with the big insurance companies. Split the large insurance companies up like you said and pass a law prohibiting them from being investment opportunities. The set up itself, to have to pay investors and all their personnel demands they get that money from somewhere. They call our premiums, decuctables, and withholding payments for patient care and withholding payments to physicians..they call that "PROFIT." They have always been nothing more than a huge money grabbing middleman between the doctor/patient relationship...and we both have suffered. These insurance companies make money from all different angles..They take in money from investors and give a little back in returns...just like a casiono..just enough to make the public vote against breaking them up. They take large amounts from the premiums and deductibles which causes most insured not to be able to use their insurance. So large amounts coming in and not much going out. They keep money by denying coverage, medications, paying for CT or MRI scans. Without the scans they claim there is no firm diagnosis other than the doctors opinion, so they refuse surgical or chemo options which would keep the pt alive. They also keep money by not paying doctors for the office visit and procedures. BCBS reimbursed us 00.34 cents on many patients. They hold reimbursement for months, then bundle it with other BCBS covered pts and they know it takes us hours to figure it out and we have to pay someone $25/hr to tell us the insurance company shorted us $190.00. They know we can not take off the 3 to 4 days they would tie us up in court because it would cost us at least $30,000.00 to retrieve the $190.00. (money from all the patients we didn't see for 4 days, still have to pay our staff to sit and do nothing while we are in court, and attorney expenses..and they all work for each other..they bill us for calls they do not make to the other attorney. They also will settle with each other on the 1st day but will not tell either party, so can keep billing both sides. I used to work for a large group of attorneys and I complained about this practice and they told me to "wake up, all attorneys do this and to get to work and send out those bills." Also the patients, employers and schools are going to have to be realistic. Right now they expect their insurance company to pay for a Motrin or a band-aid. Schools force parents to pay for a doctors visit if their child has a stomach ache and stays home for a day. Employers force employees to pay for a doctors visit before coming back to work if they stayed home with a 3 day flu virus. All unnecessarily spending of someone else's money they don't have..so the pt has to push it off on the insurance company or they get medicaid and we tax payers pay for it. Medicaider's come to the ER for non emergent issues. Illegal aliens come to the ER at 4AM and bring all of their 6 children for "check-ups." They insist I write them antibiotics for illnesses which they do not have "or they are going to complain and I will be fired." And the sad thing is, I will be. Most likely their is an adult who is sick at home they are trying to get the antibiotics for or as I have seen with my own eyes, they sell them at their flea markets for a few dollars. Now we are competing with non physicians who are practicing medicine at flea markets. While we physicians must hire certified people, and have equipment monitored and tested for accuracy and pay for inspections etc. One of the newest competitions springing up is the "office managers gone rouge" They steal the physicians patient data, names, addresses, phone numbers, and open up their own practice. after they have made a complaint to the board on the physician they use to worked for. How does this work? They steal a few pages out of the doctors script pad and write some bogus scripts, then call the physicians board and complain that he is letting other people write his narcotics..boom, he loses his license and the office manger take over the lease or moves the practice down the road and hires a recruiter to find another doctor and tells them its a corporate owned practice but he is the medical director and they pay the new doctor an hourly rate and these non-physicians are now making money off our backs and they never finished high school. I know this because it happened to me. I was a doc hired by the recruiter...later i got them shut down. We physicians are fighting all fronts...we need to band together and refuse to take insurance until they fall to their knees. Once patients can not find anyone to take their insurance they will get angry for paying for something they can't use. We need to make patients collect from their own insurance companies...the agreement is not with us..we did not purchase this product so why are we required to pay for staff to collect our money for some luxury the patient bought. The patient today has no idea their insurance companies are not paying us. They need to know. If we put the pt back in the position of having to collect their own money back and the insurance company tries to rip off the person who feeds them...then they will be exposed for the thieves they are. It is also only the insurance company who can refuse to pay..but we are not allowed to refuse to treat...So we are being abused by the patients and the insurance companies. We are forced to see a pt in the ER who is laughing and running up and down the halls obviously not suffering from anything emergent, but they're there for a knee scrape and the Mom or Dad is there to abuse us for a handful of free band-aids, not caring that the entire ER staff now has to each make a 6 page note on some expensive EMR for this now $2500.00 band-aid..and the insurance company will either not pay, or will.. but if they pay they have to raise their rates to everyone to recoup their loss....It's a mess.
    • [email protected]
      You say "A medical practice cannot survive on visit revenue alone without seeing an extraordinary number of patients every day." You're right, and for the past 15 years the Texas Medical Association has documentation that for Medicare/Medicaid the medical practice cost/RVU is greater than the Medicare conversion rate per RVU, which means that you cannot make your practice even pay the bills by increasing the number of patients you see. This has serious future consequences for doctors and our patients. Unfortunately, our professional organizations are more interested in trying to be service organizations, than advocating for their members. Sad!

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