Is Medicaid really that bad?

[p100]

A primary care physician advised me to check the insurance demographics before moving to a location to open a practice. He said Medicaid pays very bad and you cannot make a living if you see these patients.

If someone sees 50% Medicaid is it really that bad? Are 10 Medicaid equal to 5 private insurance? Is it state dependent?

Thanks in advance.

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[Feli]

Yes.

 

[Pronation]

Yup

 

[air bud]

Being employed by a hospital a Medicaid RVU is worth the same as a BCBS RVU......so I treat people not their insurance.

PS. The Medicaid patient is crazy.

 

[heybrother]

The fee schedule for your state is online somewhere. Its probably very bad. Mileage may vary - a friend of mine was getting very close to my Medicare values for a lot of services. Reimbursement can appear relative ie. if United is destroying you with sub-Medicare then Medicaid values may not look that unreasonable by comparison. In the state of Texas a 99213 on an adult with Medicaid is $33.95.

The unfortunate truth is that when you hear someone on here says they make big number $X - its very hard to get there with tiny visits. People sometimes talk about how you need to code more aggressively - no amount of sub-$50 99213s + 20550s and what not is going to get to a real number if you start with small enough values.

If you add Medicaid - hopefully its out of the goodness of your heart / to help people. You may be bringing on new problems - I've posted this before but my nice semi-fast ASC that doesn't give me a hard time about overpriced lapidus hardware does not accept Medicaid (or most healthcare.gov plans). I have a county hospital I could take them to but every once in awhile I get put behind a liver resection.

The simple truth is for the purposes of revenue if you can find a way to add 1-2 good quality BCBS surgeries a week you are likely to crush bringing on any amount of new Medicaid patients unless you force orthotics and Tolcylen on everyone and spend 1 minute in the room. A review of my practice's collections essentially shows a steady increase in revenue ever since we stopped seeing Humana and new Uniteds. Its somewhat terrible, but we've essentially raised the encounter value floor by dropping low reimbursing visits.

I can only speak for my market but in my town only the county hospital pod and one PP podiatrist accept Medicaid. The PP podiatrist who accepts Medicaid doens't have privileges at the county hospital and the county hospital podiatrist is supposedly very basic wounds/pus. It is likely that in certain locales if you accept Medicaid you will be the only person who does so and possibly the only surgical podiatrist who does so. I read an article a long time ago about a community of doctors who all agreed to accept Medicaid together so no one practice would have to bear the burden. My suspicion is that hospital employed docs routinely feel like the local PP community dumps Medicaid on them. In short, local dynamics matter.

For my practice, a BCBS PPO 99203+11750 is worth double the Medicaid value for the same codes.
Concerning the relatively nature - United commercial pays me $1 more than what Medicaid does for a 11750.

Whenever you read an article online talking about the relationship of Medicare to practices and overhead - know that there are no totally hard and fast rules. Its always about your local dynamics and areas. Article writers on line routinely claim that Medicare pays less than commercial insurance when for private practices that is not always the case.

 

[Feli]

... My suspicion is that hospital employed docs routinely feel like the local PP community dumps Medicaid on them. ...

Suspicion? That should have been confirmed by around 0.4yrs out of residency.

A primary care physician advised me to check the insurance demographics before moving to a location to open a practice. He said Medicaid pays very bad and you cannot make a living if you see these patients...

You can make a living... a very bad and very tough living.

Some DPMs or docs of other types do it (high % of MCA pts). I have seen it done. They have to see a very high volume of pts, run skeleton staffing, work harder, do fake grafts and wound wizardry to ty to bill enough to make ends meet... that type of stuff. Most docs honestly have associates see those pts/clinics. At least office rent/buy is typically cheap in heavy MCA areas, which are often immigrant/port areas. Many of these docs are your FMGs or struggled on boards and not exactly hospitals' and PP's top candidates for other jobs. Some docs are quite smart and good but just immigrants themselves and speak the local secondary language(s), and want to give back... so that's cool.

Most PP docs do the opposite... avoid those MCA appointments and avoid heavy-MCA areas or networking with PCPs who have a lot of those pts. It's a source of frustration and lost income. As if it didn't pay low enough, many MCA pts will no-show, show up early/late, poor compliance, needed Rx or tests will get rejected, etc. It should be no wonder than nearly any MD or DPM doc in PP dumps it on the hospital docs who are paid for call or paid regardless of pt's insurance. Tale as old as time.

...You will always have a tiny bit of MCA primary pay anywhere (mostly through ER), and you will learn how to deal with it. I just see them and consider it doing charity (I'm not at all religious, but it makes it easier to handle seeing the no-pays and pathetic reimbursements which will ensue). Work comp can be that way also... area-dependent.

For private practice as a specialist, the most important factors for success are - in order:
1 area payers mix
2 area saturation (will be anywhere from avg to high to extreme for podiatry... low to avg for most MDs)
3 good personality and networking with PCPs and staff and community
4 good skill set/results

And sure, it should probably be the exact opposite order of importance... but that's just not how it works.

 

[Adam Smasher]

I see a lot of medicaid and I find it pays quite well










...for diabetic shoes

 

[heybrother]

Suspicion? That should have been confirmed by around 0.4yrs out of residency.

The more amusing realization was when I went PP and my patients actually got better.

 

[Pronation]

The more amusing realization was when I went PP and my patients actually got better.

HOT TAKE: the even more amusing realization was when I went PP to RVU and my patients became borderline farm animals but my pay exploded.

 

[heybrother]

Exploded doesn't seem appropriate to describe my pay. Dilated? My kids get their own quesadilla now rather than splitting one, but they still share a lemonade. We had part of the kitchen redone in the sense that my wife tiled it herself. There's a tile over the sink that sticks out a little further so when the light shines down on it you can see a shadow. We hang a wreath there.

 

[Pronation]

Exploded doesn't seem appropriate to describe my pay. Dilated? My kids get their own quesadilla now rather than splitting one, but they still share a lemonade. We had part of the kitchen redone in the sense that my wife tiled it herself. There's a tile over the sink that sticks out a little further so when the light shines down on it you can see a shadow. We hang a wreath there.

Very nice. Thanks for sharing a recent podiatric home renovation.

 

[Hybrocure]

They only show up for appointments about 60-70% of the time. Many are complicated patients (lots of post traumatic arthritis, multiple comorbidities, all the other good surgeons in town don’t take their insurance).

Medicaid peds patients are a good source of a lot of ingrowns and orthotics though.

 

[619]

Yes it is bad but not that bad. In my state, medicaid does not cover DME so you have to give them rx and send them to hanger if they need DME.

Starting out, you obviously want to see every new patient. The key to treating medicaid patient is to see them one and done. New medicaid patient comes in for heel pain, New patient visit plus inj and x ray pays around $180 total. New patient and 11750 pays around $220. New patient wart pays around $160 also. Also remember these are quick visits that take less than 15 mins. So getting paid $200 for 15 mins work is not bad.

Obviously follow up appointment pays less. See them once and discharge. Send to physical therapy, write rx for DME etc if needed all at that one visit. I don't reschedule follow up appointment because as others have said, they no-show or show up late. A medicaid ulcer comes up, if not infected and does not need surgery, I quickly send to wound care clinic.

Patient with neuropathic pain comes in asking for surgery to fix their bunions, hammertoes or whatever with patient thinking the surgery will fix the neuropathic pain, just say NO. Save yourself the headache and burnout. I don't care if I need numbers for boards, I have no interest in doing elective surgery on a patient with neuropathy. I see people do it just to get the so called surgery numbers. Anyway that's a topic for another day.

BCBS or private insurance pays 2x or more and when you add DME then you are looking at 4x more than a medicaid new patient.

 

[p100]

This is sad to hear.

I just looked up my states Medicaid reimbursement and it says
99203 $90
97597 $77
11721 $33
11056 $62
20600 $40
11750 $121
73630 $26

This looks decent to me.

 

[Pronation]

This is sad to hear.

I just looked up my states Medicaid reimbursement and it says
99203 $90
97597 $77
11721 $33
11056 $62
20600 $40
11750 $121
73630 $26

This looks decent to me.

Those numbers are awful dude

 

[heybrother]

This is sad to hear.

I just looked up my states Medicaid reimbursement and it says
$90 for a 99203.
$77 for 97597.
$33 11721.
$62 11056.
$40 20600.
$121 11750.

Are the numbers they give higher than what they will actually pay?

Government online fee schedule values are usually accurate unless there's government budget games going on. Like last year or something they cut the Medicare RVU but did it phased so the values 6 months in were 1 % lower or whatever but might not have been reflected in the online charts.

I think everyone at some point in time has thought "should I accept Medicaid" and then they looked up their state values and cringed and wondered how they'd make it work. I've been lead to believe that in a lot of states Medicaid pays for a pair of custom orthotics a year and so a bunch of people do it just for that. If true, very ...podiatric.

 

[air bud]

Anyone got any jobs?

 

[Adam Smasher]

@p100
I wanted to give a more serious response to this. Treating a medicaid population is challenging but has some upsides. Feli is correct, to treat this population I need to see a high volume and I don't have the support staff I would like. And yeah I put it hard hours but each little bit adds up. So in a word, I won't say it's good or it's bad, just different.

Yes medicaid patients miss their appointments. Sometimes it's a simple matter of transportation: they arrive when the bus gets off in front of my building. The more salient issue is copays. If you have to pay something out of pocket for each dr appt, you're not making that appt unless you know you have a problem. If your copay is $0, you can make and break appts on a whim. Or worse: if you like your doctor, you keep on visiting over and over again for every bump and bruise (this is my experience with one patient).

This is why in discussions about health economics, you keep hearing that patients need to have "skin in the game." Anyone who believes healthcare is a universal uninfringeable right needs to spend a day in my clinic with me. My medicaid patients take time out of their day to visit me simply so I can prescribe shoes, moisturizing cream, canes, shoes, OTC tylenol, and shoes.

However, it's not all a waste of time. Sometimes you see some really interesting pathology that is beneath other doctors' dignity to treat. I guess its up to you if you want to go the extra mile for this person or not. Some people are decent and appreciative, others are flakes. You have to be a Vegas poker dealer trying to read a person if they're going to be a headache or not. I have made it my policy to give these people the benefit of the doubt, which I guess means I'm not 100% jaded yet.

One nice thing is that medicaid patients never complain about copays or deductibles. They never complain that the MRI you order to rule out a stress fx cost them $2k. They never complain why should I pay this bill when the doctor didn't even do anything for my 5 year old's untreatable toenail dystrophy.

While medicaid patients are a crap shoot, my BC patients tend to be people who already went to an orthopedic surgeon who said they didn't need surgery, gave them a CAM boot and they feel 90% better, but they just want to make sure they're ok...

Anyway, this is where I fall back on my jokes about how being a [medicaid] podiatrist is like being a lobster. You're a bottom feeder, taking the stuff that falls through, no hope of rising up. But on the flip side, I might not thrive but I'll always survive. Lobsters have been around 250 million years, so we know there's job security in bottom feeding. Homo sapiens haven't even made it 200k years and we're already on the verge of destroying ourselves with nuclear weapons, nanotechnology, AI, climate catastrophes, etc.

 

[air bud]

Also be understanding coding rules....using social determinants of health means most of these Medicaid's are level 4 visits.

From the AMA chart:

"Diagnosis or treatment significantly limited by social determinants of health"

Moderate risk.


And I just realized I need to be doing this more and should be coding at a higher level

Look up social determinants of health. Epic does a great job of showing a pie chart of them.

Smoking, transportation etc....

Edit:

Ok here you go

Economic stability, education access and quality, healthcare access and quality, neighborhood and built environment, social and community context.

 

[Boba Foot]

This is sad to hear.

I just looked up my states Medicaid reimbursement and it says
99203 $90
97597 $77
11721 $33
11056 $62
20600 $40
11750 $121
73630 $26

This looks decent to me.

Take those numbers and then take out 60-75% that your PP boss will take out of it, and it won't look so decent anymore.

 

[icebreaker32]

Why even discuss opening a private office with plans of seeing lots of Medicaid patients?

Because Podiatry

MDs/DOs only see lots of Medicaid if they are employed by hospitals or FQHCs for a reason. The exception would be pediatricians, but they have added financial incentives by Medicaid to see patients that podiatrists do not receive. They are also the lowest paid specialty for a reason.

It would be nice if their was low hanging fruit in this profession, but due to saturation there is not much available. Working for a mobile podiatry company, if you want to call that fruit (I would not) is as close as it comes.

Although good for some laughs and it has worked out for Adam Smasher, I am not of the opinion office based “lobster podiatry” is necessary a safe option for others for survival. If an area is not already saturated there is likely a good reason for that. Opening in area with a poor insurance mix is risky, but admittedly many other options after residency are also risky,

 

[DMEpod]

I don't accept any medicaid. Interestingly most of the PP pods around my area do accept it. There are some benefits to it but that patient population can bog down a clinic quickly if it's a heavy focus of your practice. There is a place for it in PP but that is location dependent and also depends on how your clinic is run. A large portion of my referral base is upper middle class higher level private carriers with 1/3 medicare pts. They typically don't like to be in a waiting room full of medicaid pts

 

[Pronation]

Lobster podiatry. Amazing.

 

[Shiyuan]

 

[Adam Smasher]

Lest you think too highly of yourselves, never forget: all podiatry is lobster podiatry

 

[icebreaker32]

Lest you think too highly of yourselves, never forget: all podiatry is lobster podiatry

There is nothing wrong with seeing lots of Medicaid patients if you can make it work for you.

In some areas many podiatrists accept Medicaid if it does not get out of hand and in other areas hardly any do.

Yes, if we are being honest our specially started because of and continues to depend on lobster medicine and surgery of the foot/ankle.

 

[Hybrocure]

I don't accept any medicaid. Interestingly most of the PP pods around my area do accept it. There are some benefits to it but that patient population can bog down a clinic quickly if it's a heavy focus of your practice. There is a place for it in PP but that is location dependent and also depends on how your clinic is run. A large portion of my referral base is upper middle class higher level private carriers with 1/3 medicare pts. They typically don't like to be in a waiting room full of medicaid pts

Yeah this too. Imagine going to a doc for an elective surgery consult and you have some crazy homeless guy trying to talk to you in the waiting room or some guy with his foot propped up next to you with bloody pus bandages. Most educated/rational people won’t judge, but a lot will wonder what kind of place you’re running especially if they aren’t familiar with podiatric surgery (why is the guy next to me missing toes? Did the surgeon screw up? He’s bleeding why aren’t they doing anything?) etc.

 

[dtrack22]

If you are going to see Medicaid, then you have to accept Medicaid referrals. The floodgates will likely open at that point depending on if anyone else in the area is doing the same. The best way to manage the horde, at least that I’ve seen, is to limit how many Medicaid patients you see in a day. You throttle them by limiting the # seen per day which could put new appointments out 1-2 months, possibly longer. These people don’t pay for anything and will usually end up in a UC or ED before the appointment with you. Or their primary will take care of it depending on what it is. You can also refer them out for surgery if that’s an option (local hospital doc who doesn’t care about insurance or local PP who is desperate enough to accept those reimbursements).

 

[Pronation]

Yeah this too. Imagine going to a doc for an elective surgery consult and you have some crazy homeless guy trying to talk to you in the waiting room or some guy with his foot propped up next to you with bloody pus bandages. Most educated/rational people won’t judge, but a lot will wonder what kind of place you’re running especially if they aren’t familiar with podiatric surgery (why is the guy next to me missing toes? Did the surgeon screw up? He’s bleeding why aren’t they doing anything?) etc.

Oh yea. I love when my 22yo bunionectomy gets seated next to the homeless TMA.

 

[619]

I don't accept any medicaid. Interestingly most of the PP pods around my area do accept it. There are some benefits to it but that patient population can bog down a clinic quickly if it's a heavy focus of your practice. There is a place for it in PP but that is location dependent and also depends on how your clinic is run. A large portion of my referral base is upper middle class higher level private carriers with 1/3 medicare pts. They typically don't like to be in a waiting room full of medicaid pts

This is why I will rather see 15-20 patients a day with real pathologies (good private insurance) and half of them new patients than see 40+ with half them being medicaid/nails. Any so called busy podiatry office is filled with medicaid patient or medicare nail patients. Then they get so busy and hire an associate to ride the nail train with them or the smart ones get residents/students to rotate through and run the nail jail.

So just because the pod office next door is "busy" and booked out for 3 months does not mean anything in terms of revenue and collections.

 

[619]

Also brings back to the point on folks that do charcot recon, IM Nail and big cases on medicaid patients that end up in BKA anyway. I spend more time talking a medicaid patient out of surgery than the few medicaid patients that I have operated on that truly needed surgery and benefited from the procedure.
It's very easy to ramp up your surgery case numbers doing surgery on every medicaid patient that walks through the door but is it ethical?

 

[p100]

Those numbers are awful dude

Still better than working for someone else.

@p100
I wanted to give a more serious response to this. Treating a medicaid population is challenging but has some upsides. Feli is correct, to treat this population I need to see a high volume and I don't have the support staff I would like. And yeah I put it hard hours but each little bit adds up. So in a word, I won't say it's good or it's bad, just different.

....

Anyway, this is where I fall back on my jokes about how being a [medicaid] podiatrist is like being a lobster. You're a bottom feeder, taking the stuff that falls through, no hope of rising up. But on the flip side, I might not thrive but I'll always survive. Lobsters have been around 250 million years, so we know there's job security in bottom feeding. Homo sapiens haven't even made it 200k years and we're already on the verge of destroying ourselves with nuclear weapons, nanotechnology, AI, climate catastrophes, etc.

If Saul Goodman were a podiatrist.

Also be understanding coding rules....using social determinants of health means most of these Medicaid's are level 4 visits.

From the AMA chart:

"Diagnosis or treatment significantly limited by social determinants of health"

.....

Economic stability, education access and quality, healthcare access and quality, neighborhood and built environment, social and community context.

Very nice info. Thanks

Take those numbers and then take out 60-75% that your PP boss will take out of it, and it won't look so decent anymore.

With a private practice it is better pay, subtracting half for overhead, than the current private practice set up of 30% commission.

 

[Pronation]

Also brings back to the point on folks that do charcot recon, IM Nail and big cases on medicaid patients that end up in BKA anyway. I spend more time talking a medicaid patient out of surgery than the few medicaid patients that I have operated on that truly needed surgery and benefited from the procedure.
It's very easy to ramp up your surgery case numbers doing surgery on every medicaid patient that walks through the door but is it ethical?

In my opinion, after I’m finished doing their 30 RVU case, if I can delay them from having a BKA by even a couple months then the case was a success.

 

[Adam Smasher]

If Saul Goodman were a podiatrist.

and yes many of my clients have criminal records

 

[DYK343]

Just had 3 medicaid patients no show in a row
All 3 were confirmed they knew about their appointment time and location yesterday.
I'm wRVU so when they actually do show up it doesnt matter to me their insurance
But with their constant no show rates - its no wonder no one wants to see medicaid patients.

 

[Adam Smasher]

Lobstering isn't glamorous

 

[AttackNME]

If we’re lobsters then what are gen surgeons?

 

[Pronation]

If we’re lobsters then what are gen surgeons?

Doctors

 

[dtrack22]

Just had 3 medicaid patients no show in a row
All 3 were confirmed they knew about their appointment time and location yesterday.
I'm wRVU so when they actually do show up it doesnt matter to me their insurance
But with their constant no show rates - its no wonder no one wants to see medicaid patients.

Yup. Had a new patient “urgent” 5th met fracture in a Medicaid kid that no showed today. It’s not really urgent so it doesn’t matter, but it’s an appointment slot that I could have gotten paid for that just went blank.

 

[Hybrocure]

Yup. Had a new patient “urgent” 5th met fracture in a Medicaid kid that no showed today. It’s not really urgent so it doesn’t matter, but it’s an appointment slot that I could have gotten paid for that just went blank.

Currently sitting in office waiting 40 mins til my next patient cuz 2 medicaids didn’t show