Confessions of a Pediatric Practice Consultant

That's right - the AAP decided to get out of the seminar management business (at least for now) and we were asked to step in. Which we were grateful to do (thanks, Dr. Lander!).

Unless you are the king or queen of coding, get yourself to NYC on Aug 22, the day before the big PriMed NYC event, and see for of the heaviest hitters in pediatric coding matters. From the release:

This is an intensive, one-day session focused on important pediatric issues that effect your practice every day. You'll master the coding basics, get answers to your specific questions during Q&A sessions with our pediatric panel, and gain valuable insight on timely topics about immunizations, pay-for-performance programs, physician compensation, and more. Our expert panel of instructors include AAP Fellows Richard Lander, MD; Chip Harbaugh, MD; Joel Bradley, MD; and Richard Tuck, MD.

I'll be there, too! Sign up and get what you deserve. Class titles include "Who Wants to Be a Coding Millionaire?", "Give Me The Money: How to Collect Your A/R", "The Codes You Miss", "Pediatric Physicians Compensation Models" and more.

It's difficult to narrow down the math stories to just one, there are so many, but here's this week's for a start. From one of the only payors who behaves worse than United/Oxford, a letter to a client of ours in the northeast:

The best offer the [we] will provide to your practice is 100% of
2007 Medicare for E&M codes only for a two year term. If you choose to
accept the range of CPT codes we discussed within E&M, [we]
will offer 105% of 2007 Medicare for a two year term.

As we discussed, there will be no enhancements offered for lab services or
immunizations/vaccines. Although we understand your dissatisfaction with
the current reimbursement structure, our position on this has not changed
regarding the negotiation.

Please advise as to how you would like to proceed.

I know how I would have liked them to proceed, but this practice is more reasonable.

Still, the math is out on the table. Which would be better for your practice - 100% of all E&M codes (99201-15 and 99381-95) OR 105% of just the established codes (99211-5, 99391-5) with all other codes at your existing rates?

Here's today;'s hint: do the math. Whenever an insco gives you a choice, there's one that benefits you more than the others. My gut instinct - and the practice's - was that 100% across all the E&Ms was the way to go. But I took the time, and did the math. Which the insurance companies never expect you to do.  Otherwise, why are they even giving you a choice? The results?

The difference, based on the last 12 months of business, between what they are paid now and the deal I would have taken without looking: $180,000. With the second deal? $205,000. That's a $25,000 difference which, in pediatrics, is real money. They are taking the second deal.  Looks like the insco had a $200K limit they were trying to stay under and, by giving you a choice, increased their odds of beating their own self-imposed limit.

Note that this is a small/medium sized pediatric group who just negotiated a +$200K deal on its own with a significant payor.  Awake, sleeping giants indeed.

Over the next few days, I'm going to post a sampling of stories of the things I've seen from our clients just this week regarding insurance negotiations. As so perfectly put by Dr. Rogu in a recent comment, awake sleeping giants! Identifying information has been removed.

So, from client #1:

...after review and some quick negotiation, it was obvious they were not willing to budge. We were done. A few companies had moved to [HMO] but not a major problem. Recently (the July 1 thing) the [local] union decided to go with [HMO]. Moms asked what they needed to do to get us to sign with [HMO]. I replied to two that we had reviewed the contract and there were major problems. Unfortunately, [HMO] was unwilling to make any changes. Naturally, I added, "They may listen to you. We would be willing to talk more if [HMO] is willing." I could almost hear you whispering in my ear, "That is just what you should say."

These moms, along with several of their friends who also bring their children to us, went to the enrollment meetings and talked to the union officers. I will avoid the specifics, but it wasn't pretty. Within one week, [HMO] reps were back talking to us and with a significantly higher reimbursement rate. Of course, we wanted to see the entire schedule and noted vaccines were paid at a low rate (their "purchase price" was below AWP). They did offer to allow us to enter their buyer's group. Secondly, we negotiated an increase in codes that had no "Medicare value" from the 60% you mentioned in your post to 80-85% depending on the plan. This improved the non listed administration fee from 60% of billed charges to 80-85% of billed charges.

After discussion, we have decided to "adjust" the administration fee for imms administered to [HMO] patients to reflect our administration costs INCLUDING the cost of ordering, storing, and cost of money. We are happy with this and think it is cool that Partner already has this capability.

Always one to keep pushing our clients, I asked: "How much is the difference worth?"

The answer?

It is my understanding that payment went up 20-25% in the 140% of Medicare for E&M codes. Total counting lab, x-ray, and imms put us at 125-130% of Medicare.

Anyone else here routinely getting 125-140% of Medicare?

There are many great things about this post, but there's one huge lesson to learn:

Don't tick off the moms.

Just ran into this fascinating site. It's the mp3-blog from the Journal of Medical Practice Management. Some of the pieces are excellent (though I don't think that small groups are going to become a novelty...).  The refers to a group of our customers later in his discussion, which is interesting.

When we first began working with various immunization registry programs over 10 years ago, we were really excited. What a great idea! All the data is there, why not use it to improve healthcare?  PCC interfaces with 15? 20? different states, for free, because we think it's such a good idea.

I even had a chance to speak at the CDC to a room full of uniformed health officers about the use of billing records to track immunizations. We'd been doing it for years with our clients with great success - printing school forms at the touch of a button still knocks the socks off most practices - but the CDC folks wouldn't buy it. "There's no way the billing data can be accurate. There are too many errors in the process!"

"Um," I replied, "how many billing mistakes, especially for imms, do you think a private practice can afford? If someone at the front desk isn't right 99.9% of the time, the practice loses a fortune. It may not be perfect, but it's more accurate than 1000s of people double-entering the data into some poorly designed UI from a state system."

That didn't go over well, to my surprise. Soon after that, we got in an argument with a particular state registry. I remember taking the call. "What do you mean you want to record the physician's social security number WITH EACH SHOT? That's crazy!"

It was then I realized that, too often, the goal of the registries isn't to improve immunization rates. It really isn't. If it were, we'd skip the docs and go straight to the insurance companies. They have all the data. In most states, getting the data from Medicaid (which the state controls anyway...) and BCBS would wrap up the imms records for 1/2 the kids, especially those most likely to need immunizations. But, no, that doesn't happen.

What I've been waiting for is the first official moment of punitive use of registries.  I expected that some state, based on comments we'd all heard from them during the interface process, would start punishing doctors whose data wasn't up-to-snuff.

To my surprise, one of the more effective and aggressive registries, has taken it a step farther.  Though I can't confirm this and I actually hope someone calls to tell me I'm wrong (and I'll gladly apologize and correct), it looks like that the state of Michigan will require you to use the registry if you want to get VFC vaccine.

Think about it for a second.  Doesn't this really mean that there will be physicians who won't or can't comply?  Which means that, ultimately, you've denied them VFC vaccine?  Which means that some kids will not be vaccinated?

Isn't this the opposite of how a registry should work?

I see a small pile of 1/2 finished entries. My travel schedule is making it difficult these days!

Some good, interesting news from the Medical Society of New Jersey:
May 14, 2007:

Senate Bill No. 2652 and Assembly Bill No. 4182 sponsored by Senator Joe Vitale and Assemblyman Herb Conway, addressed the new policy of reimbursement of childhood immunizations. The bills stated that the reimbursement must reflect the reasonable cost of acquiring, maintaining, and administering childhood immunizations as determined by the commissioner of the New Jersey Department of Health and Senior Services. This bill is in line with MSNJ Resolution 19 which requires MSNJ to seek legislation to assure that insurance companies adequately reimburse for immunizations.

There were also great, important pieces of info about S-CHIP funding and DOBI's legal action against UHC, but this was the best part. I realize it hasn't passed, yet, but I like reading this kind of language:

...a civil penalty to which a health maintenance organization as specified in subsection a. of this section that fails to comply with the requirements adopted by regulation pursuant to that subsection shall be liable, which shall not exceed $1,000 for the first violation, $5,000 for the second violation, and $10,000 for the third and each subsequent violation...

A customer called me yesterday to ask, "[Evil Empire HMO] has finally come to the table and is offering me 100% of Medicare on my E&Ms...should I take it?"

Normally, I'd say, "100%?  That's a joke."  But this client was calling from a part of the country where pediatric practices average 65-75% of Medicare.  I know of at least three groups (of 5-20 practices each) within 70 miles of of this practice who are trying to merge for the stated purpose of negotiation.  So, here we have a small practice getting one of the worst HMOs to the table on their own.  I figured I'd better check to see what the deal would be worth.

We spent a few minutes in Partner.  If just their 99211s through 99215s are raised to 100% of Medicare, the practice will bring in an extra...$175,000.  Every year.  For for just this one payor.

We quickly agreed to ask for 100% of all codes (you always have to ask), but take 100% for a one-year contract.  And ask for 105% or 110% next year.

Next time you think you need to be big to negotiate, remember this, Example #754.

Sorry, benchmarks will have to wait. It'll be worth it, though.

Poking around Google is a notorious pasttime but, as we all know, it sometimes pays off. Today, a click-here and a click-there, and I ended up on the long running blog of Reed Tinsley. Although I definitely don't agree with everything he says, more often than not, his stuff is on the money (pun intended). Good stuff in there, read it.

I contacted him through his on-line form and his reply-bot sent me a copy of his latest newsletter which, not unlike his blog, has good copy - just more in-depth and with guest writers. Whom do I see listed at the top of this month's newsletter? Randy Bauman, of Delta Healthcare, who took very good care of some of our clients in NJ last year. Read the piece about overhead and the mistakes docs make, it's excellent.

It's like living in Vermont. You can't walk down the street without recognizing someone. Is that a bad thing?

I was going to write about some cool pediatric benchmark data we've put together today, but I find this story more important and compelling. Check out Dr. Stoller's mission to Ghana on CBS.

Six years ago his mother abandoned him and his younger sister in the woods of Ghana because they were both blind. They were only 11 and 8 years old.

For three months they drank rain water and ate food from a nearby garden until a passerby brought them to an orphanage.

Reading about these kids helps me put my complaints into perspective. Thank you to the folks from OCI for doing the work for us.

It dawned on me that it would be helpful to let people know about valuable pediatric resources. For example, I expect to do a quick review of groups like Physicians' Alliance and Pediatric Federation soon.

I'll start with a self-reference: PCC's Pediatric Practice Management Conference on July 19 in Vermont. We've got Donelle Holle, Drs. Hagan and Lessin, Rosemarie Nelson, and Carol Rutenberg. Big names, great topics. Plus, Vermont is beautiful in the summer time. Can't be beat.