Avery--Medicare, money: ABN'S/INSURANCE

November 24, 2004

Nice and informative response, Dr. Jenkins, and I agree about the spawn of

Satan. Insurance is the absolute worst part about practice by far.

I just wanted to add (and I'm sure you are aware of this, but others may not

be) that although personal injury (PIP) auto cases DO require more paperwork

and attorneys (both sides) will want sometimes repeated chart notes, a fee

can be made on each batch sent. I typically charge $35-50 each time they

ask (it's especially irksome when I've included chart notes with each

billing). So, for 10-15 minutes of my time making copies, I can make

$35-50. Some people charge more, some charge nothing at all. It's a

personal call.

_____

Dr. Avery L. Jenkins [ajenkins]

Wednesday, November 24, 2004 5:36 AM

Chinese Medicine

Re: Avery--Medicare, money: ABN'S/INSURANCE

Laura,

It depends on the plan. In the HMO plans, if I am a participating provider,

I am prohibited by my contract with the HMO from balance-billing the patient

for the difference between what the HMO pays me + patient co-pay, and what

my standard fee is. Because of this, I only participate in 2 HMOs.

However, if I am not a participating provider, it often works out that there

is a deductible; until the deductible is met, the patient pays the standard

fee, after which the insurance company pays me a percentage of my standard

fee (usually 50-80%) and the patient pays me the outstanding balance.

The ABN form is only a Medicare requirement, Medicare plays by its own

rules; however, I or my staff always discuss the insurance situation with

the patient up front, so nobody gets any nasty surprises.

In personal injury cases, I bill my standard fees, for which the patient is

fully responsible. If there is insurance coverage, I will bill the auto

insurance; if they are represented by attorney, I have the patient sign a

lien, which states that I will be fully paid out of the patient's

settlement. While good money, PI cases usually take 2-6 years to resolve;

paperwork problems increase, in that the attorney always wants copies of the

clinical notes and usually a report. The attorney may also seek to cut your

fees at the last minute if the settlement comes out to less than expected.

The insurance companies will also seek to cut your fees in out-of-network

and PI cases as well, stating that they are responsible only for UCR (Usual,

Customary and Reasonable) charges, which somehow are always less than what I

bill.

It looks like the wave of the future is going to be plans with high

deductibles -- $1,000, $2,000, or $5,000 -- after which insurance kicks in.

In short, disaster insurance. Which is great for those of us in alternative

health, because on a level playing field, I can treat many conditions at

much less cost to the patient than western medicine.

My approach to insurance companies highly adversarial. I regard them all as

Spawn of Satan.

Avery L. Jenkins, DC, DACBN, FIAMA

November 25, 2004

Hi Avery and all, LOL, I think you are wise to recognize an enemy

when you see one. I swear they make up reasons to put off payments

(and then just let the bill sit there until I call them).

I ask most of my patients to pay at the time of service. I tell them

this on the phone when they make the appointment, and most of them

are fine with it. However, if they cannot afford to do so, I make

exceptions. So far this has worked great, but I don't know if

problems will come up (I'm pretty new to this). Its very satisfying

getting paid right then and there for the hard work I put into each

and every one of them. Keeps me motivated--a win-win situation.

Even if the ABN form is only for medicare, I'm thinking that the

concept may be useful to us. If I am billing HMO's for elbow pain

but also treating low energy, poor sleep, and depression I think that

it might work to tell the patient that the insurance is paying this

amount for the work we are doing on your pain, but you need to pay

the additional amount (up to my regular fee) to cover the other work

we are doing. That makes sense to me---What do others think? Perhaps

if we rallied around this idea we could make it a standard way that

we practice as acupuncturists. It really seems only fair if you ask

me.

Thoughts anyone?

Also, is there a simple way to know whether an insurance company is

an HMO or not? (I suspect that question has made me look really

clueless...)

Laura

Chinese Medicine , " Dr. Avery L.

Jenkins " <ajenkins@c...> wrote:

>

> Laura,

>

> It depends on the plan. In the HMO plans, if I am a participating

provider,

> I am prohibited by my contract with the HMO from balance-billing

the patient

> for the difference between what the HMO pays me + patient co-pay,

and what

> my standard fee is. Because of this, I only participate in 2 HMOs.

>

> However, if I am not a participating provider, it often works out

that there

> is a deductible; until the deductible is met, the patient pays the

standard

> fee, after which the insurance company pays me a percentage of my

standard

> fee (usually 50-80%) and the patient pays me the outstanding

balance.

>

> The ABN form is only a Medicare requirement, Medicare plays by its

own

> rules; however, I or my staff always discuss the insurance

situation with

> the patient up front, so nobody gets any nasty surprises.

>

> In personal injury cases, I bill my standard fees, for which the

patient is

> fully responsible. If there is insurance coverage, I will bill the

auto

> insurance; if they are represented by attorney, I have the patient

sign a

> lien, which states that I will be fully paid out of the patient's

> settlement. While good money, PI cases usually take 2-6 years to

resolve;

> paperwork problems increase, in that the attorney always wants

copies of the

> clinical notes and usually a report. The attorney may also seek to

cut your

> fees at the last minute if the settlement comes out to less than

expected.

>

> The insurance companies will also seek to cut your fees in out-of-

network

> and PI cases as well, stating that they are responsible only for

UCR (Usual,

> Customary and Reasonable) charges, which somehow are always less

than what I

> bill.

>

> It looks like the wave of the future is going to be plans with high

> deductibles -- $1,000, $2,000, or $5,000 -- after which insurance

kicks in.

> In short, disaster insurance. Which is great for those of us in

alternative

> health, because on a level playing field, I can treat many

conditions at

> much less cost to the patient than western medicine.

>

> My approach to insurance companies highly adversarial. I regard

them all as

> Spawn of Satan.

>

> Avery L. Jenkins, DC, DACBN, FIAMA

>

> -

> " heylaurag " <heylaurag@h...>

> <Chinese Medicine >

> Tuesday, November 23, 2004 7:13 PM

> Re: Avery--Medicare, money: ABN'S/INSURANCE

>

> >

> > Hi Avery and all, Maybe you know the answer to this question, or

maybe

> > someone else does. My understanding is that we cannot bill the

> > patient beyond what their insurance pays plus the co-pay. Is that

> > accurate? If so, I was wondering if we could use a form like the

ABN

> > that you mentioned to get paid beyond what their insurance pays.

> > Anyone know? I find it frustrating to be paid 2/3 of what I

charge

> > when I am treating many different issues beyond the elbow pain I'm

> > billing for.

> >

> > How do others deal with this, and am I correct in thinking that we

> > cannot bill beyond the co-pay?

> >

> > Thanks,

> >

> > Laura

> >

> > Chinese Medicine , " Dr. Avery L.

> > Jenkins " <ajenkins@c...> wrote:

> >>

> >> -

> >> <acudoc11@a...>

> >> <Chinese Medicine >

> >> Monday, November 22, 2004 10:17 PM

> >> Re: Medicare, money..

> >>

> >> >

> >> > When one compares their treatment to a Chiropractic adjustment

or

> > as an

> >> > Acupuncturist

> >> > technician then I guess that person will get the bottom of the

> > barrell for

> >> > reimbursement.

> >> >

> >> > If one acts like a primary care provider and bills accordingly

> > they won't

> >> > wind up with $20.

> >> >

> >>

> >> Huh??

> >>

> >> What Medicare pays for services has little to nothing to do with

> > what you

> >> bill for them. Fees are established primarily by bureacratic

fiat and

> >> approved Congressionally. If you you are a participating

physician,

> > you have

> >> the extremely negligible advantage of having Medicare

automatically

> > forward

> >> the unpaid portion of your bill to the patient's secondary

insurance

> > (if

> >> any), for potential payment of the balance. The downside of that

is

> > that as

> >> a par provider, you cannot balance bill the patient for the

unpaid

> > portion

> >> of covered services.

> >>

> >> You may, however, bill the patient your standard fee for any

> > non-covered

> >> service, but only so long as you had the patient sign an ABN

(Advance

> >> Beneficiary Notification), which states the service to be

rendered,

> > the fee,

> >> and the reason you expect Medicare to reject the bill. The ABN

must

> > be in a

> >> form approved by Medicare, which is readily downloaded off the

net.

> >>

> >> As a non-participating provider, you can bill Medicare and then

have

> > the

> >> advantage of being able to balance bill the patient for covered

> > services.

> >>

> >> You should also know that Medicare will soon be requiring all

bills

> > to be

> >> submitted electronically. This places a huge burden on you to

ensure

> > that

> >> your software can submit the bill (via a Medicare-approved

> > clearinghouse) in

> >> the proper format and that your entire office management system

> > meets HIPAA

> >> requirements.

> >>

> >> You should also be aware that Medicare, like other insurers, is

> > likely to

> >> highly restrict the diagnoses for which acupuncture treatment

will be

> >> covered, and be prepared for a 3-6 month wait (minimum) for

payment. In

> >> fact, I have many bills which have gone unpaid for as long as a

year.

> >>

> >> Avery L. Jenkins, DC, DACBN, FIAMA

November 25, 2004

Hi Laura,

I'm sure there may be someone out there with better info than mine, but here

it goes.

Basically, if you are not a preferred provider for insurance companies, you

can charge what you want, and you can have patients pay you at the time of

service (as you are doing). Are you a preferred provider for any insurance

company? If so, you are obligated to take only what they pay you and the

patients copayment. That's it.

I don't think telling the patient that their insurance company is paying for

" pain " and that they could pay for the rest will fly. That seems a little

sticky. Anyone else have comments on this?? You could possibly give them

separate treatments, one for pain to bill the insurance company and others

for whatever else ails them. I'm not positive about this. Do you offer as

" same day as service discount? " By this I mean: " My fee is $95 for the

first visit, but if you pay me the same day of service, you pay only

$85.00 " . That is legal, and it covers your pain and suffering for having to

bill either the patient (if they can't pay the same day) or insurance

company in the event you have to wait for payment. Some practitioners have

as much as 25% difference between their " real " rate (what they charge

insurance or if they have to bill the patient who won't or can't pay the

same day) and their " cash " rate. This provides incentive for the patient to

pay the same day and then turn the receipt into their insurance company.

Perhaps you are already doing this.

Good luck. I hope this helped some. I'm looking forward to other's

feedback as this is interesting.

Barb

_____

heylaurag [heylaurag]

Wednesday, November 24, 2004 4:07 PM