Practice Management

No time like the present to take care of PRIORITY ONE!

We are helpless as we're always bowing to the dictates of payors without recourse.

We must Hang together or hang separately, folks!

Isn't it about time that we all 'compare notes' for to ensure that we are paid fairly AND ON MERIT instead of being reimbursed at the whim of the insurers?  

We should all be held to the HIGHEST STANDARD and when we are reimbursed against this standard, both providers and patients will benefit.   

Aren't we all in practice to offer the most professional level of service?  With continually decreasing reimbursements the insurers - both government and private insurers alike - are making a mockery of our efforts to HELP THE SICK and bring them back to health!

Example:  Many of the outpatient centers bordering Canada see a good volume of Canadian patients who sometimes have to wait MONTHS to receive services where these services are available across the border - for cash payment - immediately!

I just received this via email:

Recently, several large, national commercial medical insurance plans, have employed aggressive tactics against contracted physicians that only benefit commercial plans.  Most carriers have reported record profits during this pandemic, yet they are still compelled to take advantage of misguided legislation and flawed Medicare payment policies. 

Surprise Medical Billing (SMB) and Out of Network (OON) state laws were passed in an effort to remove the patients from receiving a bill.  However, in states whose SMB/OON laws do not adequately protect physicians negotiating rights, we see several carriers taking advantage of the OON legislation and terminating contracts with network providers at an alarming rate.  Federal legislation has also  been proposed, which would require that health plans reimburse OON physicians at an "in network median rate" which is known only by these plans.

• They are doing so to groups that are currently contracted at rates higher than what the statutory levels set by these recently passed laws.  Those statutory levels are often set at the "median in network" rates and require that the health plans initially reimburse physicians at this median in network rate.  Since the median rates are usually known only to the health plans if such rates are not tethered to an independent data base, the health plans have been terminating any physician participation agreements that are in excess of these rates to manage the median downward in anticipation of the federal and/or state OON laws.  
• All physician groups rely on commercial rates to offset the lower rates paid by governmental payers and self-pay.  

The result will be to decrease physician reimbursement at a time when they are stretched thin in fighting the pandemic and rebounding from cancelled elective and screening procedures.  Many hospital based physician groups saw volume decreases of 40-50% in March and April and many continue to experience volume declines of -20% today-and are expecting to see the same in the first half of 2021.

We are seeing certain carriers adopting the new valuation of E/M codes beginning in November of 2020.  As you know, CMS is proposing to change these values to compensate E/M codes at a higher level, and budget neutrality requires that other CPT codes suffer beginning in 2021. 

• CMS  is proposing this by reducing the conversion factor by 10.6%.  While we are supportive of the increases for E/M codes – we also know that many specialties will face significant payment reductions - hospital based specialties and their care teams who are the front line physicians in response to COVID-19.
• CMS and federal lawmakers are also aware and scrambling to find a fix or a delay to make sure these cuts are avoided. 

The result is that unilateral changes to carrier contracts will lead to physician shortages (especially in rural areas) at a time when these services are desperately needed. 

We are at a critical point where access to patient care will become a real issue for every state in the country.  

Tell your state's Insurance Commissioner to resolve these growing issues by putting these greedy giants on NOTICE!

------------------------------
William Kisse
COO
Washington Open MRI, Inc.
Rockville, MD
bill@womri.com
(301) 424-4888
https://www.linkedin.com/in/billkisse/
------------------------------

Bill, not only are carriers using the OON legislation to their advantage they are becoming very aggressive on implementing bundling edits that have not basis in reality.

Relative to the OON legislation, even here in TX, our lovely Department of Insurance, which is of course and independent 3rd party, right, has made applying for arbitration so administratively difficult as to discourage many providers from jumping through the hoops.

Or you have to assign a full FTE to doing nothing but this.

The result, payers costs go down, ours go up.

------------------------------
Douglas G. Kraus, CPA
Chief Financial Officer
South Texas Radiology Group, P.A.
------------------------------

Original Message:
Sent: 09-25-2020 09:55
From: William Kisse
Subject: We are DYING BY A THOUSAND CUTS!

No time like the present to take care of PRIORITY ONE!

We are helpless as we're always bowing to the dictates of payors without recourse.

We must Hang together or hang separately, folks!

Isn't it about time that we all 'compare notes' for to ensure that we are paid fairly AND ON MERIT instead of being reimbursed at the whim of the insurers?

We should all be held to the HIGHEST STANDARD and when we are reimbursed against this standard, both providers and patients will benefit.

Aren't we all in practice to offer the most professional level of service?  With continually decreasing reimbursements the insurers - both government and private insurers alike - are making a mockery of our efforts to HELP THE SICK and bring them back to health!

Example:  Many of the outpatient centers bordering Canada see a good volume of Canadian patients who sometimes have to wait MONTHS to receive services where these services are available across the border - for cash payment - immediately!

I just received this via email:

Recently, several large, national commercial medical insurance plans, have employed aggressive tactics against contracted physicians that only benefit commercial plans.  Most carriers have reported record profits during this pandemic, yet they are still compelled to take advantage of misguided legislation and flawed Medicare payment policies.

Surprise Medical Billing (SMB) and Out of Network (OON) state laws were passed in an effort to remove the patients from receiving a bill.  However, in states whose SMB/OON laws do not adequately protect physicians negotiating rights, we see several carriers taking advantage of the OON legislation and terminating contracts with network providers at an alarming rate.  Federal legislation has also  been proposed, which would require that health plans reimburse OON physicians at an "in network median rate" which is known only by these plans.

• They are doing so to groups that are currently contracted at rates higher than what the statutory levels set by these recently passed laws.  Those statutory levels are often set at the "median in network" rates and require that the health plans initially reimburse physicians at this median in network rate.  Since the median rates are usually known only to the health plans if such rates are not tethered to an independent data base, the health plans have been terminating any physician participation agreements that are in excess of these rates to manage the median downward in anticipation of the federal and/or state OON laws.  
• All physician groups rely on commercial rates to offset the lower rates paid by governmental payers and self-pay.  

The result will be to decrease physician reimbursement at a time when they are stretched thin in fighting the pandemic and rebounding from cancelled elective and screening procedures.  Many hospital based physician groups saw volume decreases of 40-50% in March and April and many continue to experience volume declines of -20% today-and are expecting to see the same in the first half of 2021.

We are seeing certain carriers adopting the new valuation of E/M codes beginning in November of 2020.  As you know, CMS is proposing to change these values to compensate E/M codes at a higher level, and budget neutrality requires that other CPT codes suffer beginning in 2021. 

• CMS  is proposing this by reducing the conversion factor by 10.6%.  While we are supportive of the increases for E/M codes – we also know that many specialties will face significant payment reductions - hospital based specialties and their care teams who are the front line physicians in response to COVID-19.
• CMS and federal lawmakers are also aware and scrambling to find a fix or a delay to make sure these cuts are avoided. 

The result is that unilateral changes to carrier contracts will lead to physician shortages (especially in rural areas) at a time when these services are desperately needed.

We are at a critical point where access to patient care will become a real issue for every state in the country.

Tell your state's Insurance Commissioner to resolve these growing issues by putting these greedy giants on NOTICE!

------------------------------
William Kisse
COO
Washington Open MRI, Inc.
Rockville, MD
bill@womri.com
(301) 424-4888
https://www.linkedin.com/in/billkisse/
------------------------------