making cents of reimbursements chris sipe, md fertility centers of illinois chicago and oakbrook...
TRANSCRIPT
Making Cents of Reimbursements
Chris Sipe, MDFertility Centers of Illinois
Chicago and Oakbrook offices
Medical reimbursements
Middle Ages Colonial America 1960-70s routine care was self pay
– Major Medical Insurance– Followed home/auto concepts
1980s Advent of insurance HMO, PPO– Covered basic health and major medical
How are REIs reimbursed
No fertility coverage, i.e. Self-pay Insurance
– Maximums, benefits, rules– Employer dependent
Practice style– Private– Academic
Practice arrangement– Solo practitioner– Group Practice
Private Practice Reimbursement- Self pay
Nurses/Staff
Rent/Utilities
Equipment
Supplies
Malpractice
Marketing
$
$$
Private Practice Reimbursement- Insurance
Nurses/Staff
Rent/Utilities
Equipment
Supplies
Malpractice
Marketing
$
$$
Coders/Admin
$
How does insurance work
Employer is required by law to offer insurance to Employees– Plan must follow all state and local insurance laws
Employer can chose to add or remove coverage to suit their needs– Add pregnancy rider, mental health, infertility
Employer contracts with an insurance company to gain access to preset prices and range of services for their employees– The insurer can be paid a set fee for year to provide all services
• Budget $1,000,000 if over insurance company covers– Or insurance can pass the bills onto the employer (self-Insured)
• All bills paid by employer- harder to budget
How does insurance work
Medical offices use ICD 9 (soon to be 10) codes for listing diagnoses for patients.– Example: Endometriosis, Infertility, Abdominal Pain
This then determines what treatments can be covered by insurance for that code– Endometriosis Laparoscopy covered, BCP covered, but not trigger point inject
Medical offices then bill CPT codes to denote what work was done– Laparoscopy with fulguration of endometriosis
Insurance then pays Medical office negotiated price within 30-60 days
Rules for coding
Every CPT has a description of what it includes Clinic CPT codes require documentation of elements that were done
– Time (state amount of time spent with patient)– 3 Components: History, Physical, Consult
Only 1 CPT code will be reimbursed at a time– Others may reimbursed, but at a lesser rate
TAKE A CODING CLASS
How much does insurance pay
AMA determines Relative Value Units (RVU) for every procedure performed within every specialty that is reimbursable– Helps equate surgery to clinic reimbursement– 15minute consult with PCP is reimbursed differently from 15min with Cardiology
Insurance negotiates a price in a contract with each provider based on a conversion factor of the RVU– Medicare is the standard @ $35.28 per RVU– Some insurances force all providers to take the same reimbursement amount– “Carve-outs” special price for an individual provider due to his/her expertise
Whatever the agreed upon price a provider cannot charge the patient more
Insurance Billing from employer/ee
Total cost to insure an employee/patient is $1000 per month– Patient pays $250 per month while her employer pays $750
Clinic charges $2000 for a medical procedure (Billings)– Insurance contract will pay $1500 for medical procedure– Clinic discounts fee $500
Patient has $1000 deductible as part of plan– So patient pays clinic $1000 and insurance pays clinic $500– Clinic receives $1500 (collections)– After expenses subtracted, left with $600 (Net Revenue)
States with Infertility Mandates
15 States have enacted mandates about infertility Arkansas (Lifetime Max $15,000) California (offered, but coverage not guaranteed) Connecticut (4-6 IUIs, 2 IVF cycles) Hawaii (1 IVF) Illinois (4 IVF cycles) Louisiana (no coverage, but cannot refuse if preexisting) Maryland (3 IVF cycles) Massachusetts (IUI and IVF no limits, but rules)
States with Infertility Mandates
Montana (HMO must cover infertility) New Jersey (up to 4 IVF cycles) New York (Diagnostic testing, but not treatment) Ohio (Diagnostic testing, but not treatment) Rhode Island (Lifetime max of $100,000) Texas (Employers can decide to offer coverage) West Virginia (requires HMOs to cover infertility services)
Only 8 states truly require IVF coverage for treatment
NO THANKS, I’LL JUST GO INTO ACADEMICS
Academic Practices
Traditionally rewarded for teaching and publishing research Grant money and protected research time Less emphasis on money earned for department
Evolving as reimbursement go down and research grants dry up
The Advent of the RVU
RVU
Each hospital and department determine the relative value of an academician’s productivity
Example:– Lecture to Medical Student = 1 RVU– Director of residency = 100 RVU– Day in clinic = 5 RVU– Surgery = 2 RVU– Collections = 1 RVU per $1000 dollars
End of year RVU determine a possible bonus or next year’s pay
Academic Reimbursement
Nurses/Staff
Rent/Utilities
Equipment
Supplies
Malpractice
Marketing
$
Coders/Admin
$$$
Dean’s Tax
ResidentsFellows
More Admin
Research Grants
Graduate Medical Education
Academic Reimbursement
Not just an REI division Not just an OBGYN department Multispecialty Hospital
Hospital negotiates insurance contracts Hospital determines budgets
Thanks for your attentionAny Questions?