By Charles B. Brownlow, OD – I’ve been involved in some very frustrating experiences lately. I thought I would share them with you so that you gain perspective on your own frustrations. I was asked by an old friend practicing in another state to help find a way that ODs can bill more than their usual fees for services provided to Medicare. My friend is concerned that his colleagues’ fees are so low that they are not being appropriately reimbursed when they report those fees to Medicare. In some cases, Medicare is reimbursing multiples of the usual fees his colleagues are charging.
As a consultant, couldn’t I come up with a way around this conundrum? Couldn’t I suggest that AOA do something about this issue? Couldn’t AOA come up with a legal argument to permit ODs to violate their agreement with Medicare and bill something other than their usual charges? (A reminder: By contract, Medicare agrees to pay the lesser of the provider’s usual charge or the Medicare Fee Schedule Amount, with the result referred to by Medicare as the “Allowed Charge”, paid 80 percent by Medicare and 20 percent by the patient, after the $147 annual Medicare deductible has been met.)
Face it, some health care providers have low fees because they feel that is all their services are worth. They verify that belief by charging their private pay, uninsured patients those fees. Other providers believe their services have higher value, and they demonstrate that belief by charging real patients; private pay/uninsured patients; exactly those fees. Why is this so hard for some to understand?
Vision plans or Medicare are not responsible for establishing your fees…you are. Insurers only determine what they are willing to pay for services and/or materials. They are not responsible for determining what you will accept for your services…you are. Contracts between you and Medicare or vision plans or other medical plans are legal documents between businesses. Decisions made by businesses in contracting must be made by those businesses. Outsiders cannot influence those decisions. AOA cannot persuade insurers to change their fees or their policies. Individual contracting doctors can, but apparently too often believe they cannot and so they don’t try.
Accepting or rejecting contracts for your services without knowing your cost of providing those services is bad business and it could result in fiscal suicide, yet I’m convinced many ODs do exactly that. In a very real sense, by signing a contract without knowing whether the contract will provide any net benefit to your practice, you are simply turning over a portion of the success or failure of your practice to the insurers. Do they care about your practice as much as you should? Do they care about your patients as much as you should? Do they care about your employees, your community, your family, your retirement as much as you should? Of course not. That’s up to you.
Keep it simple. To the best of your ability, know and follow the rules of record keeping and coding and the stipulations of insurance provider agreements. Pressure your accountant and other consultants to help you determine what your fees need to be to cover your costs and create your target net income. Read the contract with each insurer annually, before renewal, and make firm, confident, informed, businesslike decisions about which to renew and which to negotiate or cancel. When masses of individual health providers take these simple steps, one practice at a time, things will improve.