QPA and the No Surprises Act

[Luvssjeter]

I am just wondering how other anesthesiologists are feeling about the QPA being, basically, the sole deciding factor for out of network reimbursement. Overtime this QPA, which is supposed to be the 50% median in network rate, will drop as there is 0 incentive for the insurers to renew your contract at high rates because if they don't, well you can get a MAX reimbursement of the 50% median in network rate. As contracts get cancelled or lower that QPA goes lower and lower.

Secondly, there is no one actually holding the health plans accountable on what their QPA determination is. If they say the QPA is $30 a unit...and I don't believe this to be true...well I'm SOL as the arbitrating entities only look at the QPA not if they are accurate. Does this make sense to anyone...? Is this a race to the bottom towards Medicare for all. Looking for insight from informed anesthesiologists that understand and do their own billing, ie Arch Guillotti. Anyone have ideas on what can save anesthesia from this point moving forward so it's not medicare for all or 150% of medicare or 200% of medicare.

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[lane]

Keep an eye on the multiple lawsuits around the country (TMA, AMA, AHA, etc.) that argue the HHS rules do not follow the initial legislative intent. It’s criminal that the QPA has essentially become the only benchmark for arbitration. And, of course, insurers have already been threatening existing contracts with insulting rates to remain in network.
Hopefully your state will be looking closely at network adequacy, as these shenanigans pushing facilities and providers out of network do create patient harm when they do not have access to appropriate care.

 

[anbuitachi]

I am just wondering how other anesthesiologists are feeling about the QPA being, basically, the sole deciding factor for out of network reimbursement. Overtime this QPA, which is supposed to be the 50% median in network rate, will drop as there is 0 incentive for the insurers to renew your contract at high rates because if they don't, well you can get a MAX reimbursement of the 50% median in network rate. As contracts get cancelled or lower that QPA goes lower and lower.

Secondly, there is no one actually holding the health plans accountable on what their QPA determination is. If they say the QPA is $30 a unit...and I don't believe this to be true...well I'm SOL as the arbitrating entities only look at the QPA not if they are accurate. Does this make sense to anyone...? Is this a race to the bottom towards Medicare for all. Looking for insight from informed anesthesiologists that understand and do their own billing, ie Arch Guillotti. Anyone have ideas on what can save anesthesia from this point moving forward so it's not medicare for all or 150% of medicare or 200% of medicare.

agree with above poster regarding lawsuits. there isnt much that can save anesthesiology at this point, so thats why ASA is also part of the lawsuit. if they fail, then get ready to have hard time paying off your medical school loans. you wont be debt free til your 50s

 

[deleted941485]

agree with above poster regarding lawsuits. there isnt much that can save anesthesiology at this point, so thats why ASA is also part of the lawsuit. if they fail, then get ready to have hard time paying off your medical school loans. you wont be debt free til your 50s

They have already said these groups have no standing and will not entertain the suits until members can show harm. So basically guaranteed to get ****ed then sue then get screwed again when you lose the suit.

 

[anbuitachi]

They have already said these groups have no standing and will not entertain the suits until members can show harm. So basically guaranteed to get ****ed then sue then get screwed again when you lose the suit.

so can anesthesiologist everywhere become cash only? stop taking all insurance?

 

[deleted941485]

so can anesthesiologist everywhere become cash only? stop taking all insurance?

Sure! Maybe they can sell their DEA number to a local drug dealer. Push ketamine. or worked in a plastic surgeons office. Otherwise no

 

[coffeebythelake]

I am just wondering how other anesthesiologists are feeling about the QPA being, basically, the sole deciding factor for out of network reimbursement. Overtime this QPA, which is supposed to be the 50% median in network rate, will drop as there is 0 incentive for the insurers to renew your contract at high rates because if they don't, well you can get a MAX reimbursement of the 50% median in network rate. As contracts get cancelled or lower that QPA goes lower and lower.

Secondly, there is no one actually holding the health plans accountable on what their QPA determination is. If they say the QPA is $30 a unit...and I don't believe this to be true...well I'm SOL as the arbitrating entities only look at the QPA not if they are accurate. Does this make sense to anyone...? Is this a race to the bottom towards Medicare for all. Looking for insight from informed anesthesiologists that understand and do their own billing, ie Arch Guillotti. Anyone have ideas on what can save anesthesia from this point moving forward so it's not medicare for all or 150% of medicare or 200% of medicare.

i foresee a lot more hospitals paying stipends to maintain anesthesia staff
good luck them finding even CRNAs for this

 

[dannyboy1]

i foresee a lot more hospitals paying stipends to maintain anesthesia staff
good luck them finding even CRNAs for this

Of course they will. The show must go on. Problem is if anesthesia is a money losing service it will be even more of a race to the bottom. Think independent CRNA’s or “covered” 12:1. Job market goes to $hit.

 

[deleted941485]

Of course they will. The show must go on. Problem is if anesthesia is a money losing service it will be even more of a race to the bottom. Think independent CRNA’s or “covered” 12:1. Job market goes to $hit.

CRNAs aren’t gonna work for **** either…or maybe they will.

 

[coffeebythelake]

Of course they will. The show must go on. Problem is if anesthesia is a money losing service it will be even more of a race to the bottom. Think independent CRNA’s or “covered” 12:1. Job market goes to $hit.

honestly in that situation i would rather just do solo work. why take the stress of supervising them and dealing with their mistakes? tough enough at 1:3 or 1:4, and now we're predicting higher ratios? crazy. i am already being paid slightly more than the CRNAs in the hospital.

 

[Luvssjeter]

Yeah I’ve heard senior anesthesia group heads saying only two things can save anesthesia; either every anesthesiologist opts out of Medicare or we are going to have to increase the “care team model” to like 1:8….ridiculous. I’m literally besides myself that more people are not aware that an asteroid is about to ruin our speciality. And The lawsuits are too little to late…

 

[dannyboy1]

honestly in that situation i would rather just do solo work. why take the stress of supervising them and dealing with their mistakes? tough enough at 1:3 or 1:4, and now we're predicting higher ratios? crazy. i am already being paid slightly more than the CRNAs in the hospital.

It’s not about what “you would rather do”. If supervision ratios increase nationwide the demand for your services will drastically decrease. Lower salary and you will do what they tell you to or someone else will…

 

[CHARLESTONMMM]

This could be the extinction event we have been waiting on. Medicare reimbursement 1/3 of private insurance and now there’s no negotiation incentive for private insurance. Will the ASA try to fix either of these problems or are they still discussing perioperative surgical home?

 

[ambiturner]

Of course they will. The show must go on. Problem is if anesthesia is a money losing service it will be even more of a race to the bottom. Think independent CRNA’s or “covered” 12:1. Job market goes to $hit.

The problem with this idea is that there’s currently not enough CRNAs to support this high of a supervision ratio nationwide. And their hourly rates have only gone up over the past 2 years and don’t seem to be affected by actual revenues. As anesthesiologists we are definitely at risk with decreasing revenues, especially if you’re in a small private group. On the other hand, if you’re a small group with reasonable rates the insurance companies may be less likely to bother you than big fish like NAPA charging the highest rates.

Given the timelines of revenue cycles, when are we likely to actually see some of these appeals play out? 6 months from now will the trends be apparent?

 

[coffeebythelake]

It’s not about what “you would rather do”. If supervision ratios increase nationwide the demand for your services will drastically decrease. Lower salary and you will do what they tell you to or someone else will…

There is not an unlimited supply of nurses and physicians that train in anesthesia. They cut anesthesja pay to point of ridiculous, the crnas would just pivot to icu nursing or something else.. this actually serves to buffer supply demand. Plus The training cycle of crnas is short enough that it is relatively sensitive to changing demands. Arguably the same situation with physicians, we've seen boom. Ust fear cycles in thr past.. what I'm saying js if offered 1:12 coverage or whatever you think might happen... I would rather go solo at a CRNA rate than have to do some ridiculous supervision ratio for slightly more pay. I would have much more job satisfaction with so much less liability and risk. In terms of time frame for any major shift like you are suggesting, probably not while the baby boomers are retiring and numbers of anesthesia providers get even tighter. Right now there remains a decent amount of bargaining power on our side.

 

[dannyboy1]

There is not an unlimited supply of nurses and physicians that train in anesthesia. They cut anesthesja pay to point of ridiculous, the crnas would just pivot to icu nursing or something else.. this actually serves to buffer supply demand. Plus The training cycle of crnas is short enough that it is relatively sensitive to changing demands. Arguably the same situation with physicians, we've seen boom. Ust fear cycles in thr past.. what I'm saying js if offered 1:12 coverage or whatever you think might happen... I would rather go solo at a CRNA rate than have to do some ridiculous supervision ratio for slightly more pay. I would have much more job satisfaction with so much less liability and risk. In terms of time frame for any major shift like you are suggesting, probably not while the baby boomers are retiring and numbers of anesthesia providers get even tighter. Right now there remains a decent amount of bargaining power on our side.

Let’s hope your right….

 

[dannyboy1]

On the other hand, if you’re a small group with reasonable rates the insurance companies may be less likely to bother you than big fish like NAPA charging the highest rates.

Given the timelines of revenue cycles, when are we likely to actually see some of these appeals play out? 6 months from now will the trends be apparent?

Actually, the way the law is written/interpreted it makes perfect sense for them to try to bargain you down, drive down the median rate, then tell NAPA to go fu(k themselves in arbitration….

 

[Luvssjeter]

Actually, the way the law is written/interpreted it makes perfect sense for them to try to bargain you down, drive down the median rate, then tell NAPA to go fu(k themselves in arbitration….

This is what I see as the problem. And there is NO accountability to the data. The data comes from the insurers, don’t think for a second they won’t give fraudulent data. Any anesthesiologists practicing in California? Isn’t this what kind of happened there….I don’t know so I ask.

In Texas the fully funded claims have an IDR process but fair health data is used and their claims data is independent of any one insurance company so it’s reliable. But with the self funded plans now just basing payment on whatever the insurer claims is their median rate, a lot of room for fraud. And obviously they will try to decrease their median in network rate. This already happened here with USAP and UHC. Rumor has it USAP signed for significantly lower than they were at per unit and that was after refusing to go in network for like 1-2 years.

And CRNA salaries will have to come down…you can’t pay CRNAs 200/hr when you’re getting 200% of medicare. And like someone else said they will just go back to ICU or traveling nursing.

Doctors Accuse UnitedHealthcare of Stifling Competition (Published 2021)

A multistate group of anesthesiologists filed cases in Texas and Colorado, accusing the insurance giant of squeezing them like a “boa constrictor.”

www.nytimes.com

Blue Cross Blue Shield of Texas to pay $10 million fine, issue refunds after state finds billing mistakes

Blue Cross Blue Shield of Texas is agreeing to pay a $10 million fine and issue refunds to consumers after a state review found billing mistakes in the...

www.dallasnews.com

 

[Arch Guillotti]

On the other hand, if you’re a small group with reasonable rates the insurance companies may be less likely to bother you than big fish like NAPA charging the highest rates.

Actually they tell you to pound sand and then won't fairly negotiate. Small groups are powerless against gigantic corporations.

 

[Arch Guillotti]

Looking for insight from informed anesthesiologists that understand and do their own billing, ie Arch Guillotti. Anyone have ideas on what can save anesthesia from this point moving forward so it's not medicare for all or 150% of medicare or 200% of medicare.

I do not do my own billing but I do talk with the company that does. Read this site, the ASA emails, anesthesiology news etc.

 

[IlDestriero]

This could certainly be a disaster for us, “surprise billing” PA dip****s and second assisting surgeons sending ridiculous out of network bills assassinated the golden egg laying goose with naked greed.

 

[Howard888]

USAP took a lower rate with United to make their numbers look better so the private equity can flip shares yet again. Some MDs may sell their shares too. So a win for PE and any old guys who sold out. A huge loss for anyone who got shares later or is a junior partner.

USAP doesn’t care. It’s not about the physicians or future. It’s about return

This law is the death of private equity groups. Rates will drop and there will be no way for Private equity to get a return without cutting salaries-which then they won’t have enough staff. Will take 5 years but these groups are done.

There will only be small medium sized private groups or more likely all anesthesia will be hospital employed

 

[gasdoc77]

So if one sells to PE, PE loosens ratios and patient care suffers (morbidity, even mortality), could one reasonably consider the buyout "blood money"?

 

[deleted941485]

So if one sells to PE, PE loosens ratios and patient care suffers (morbidity, even mortality), could one reasonably consider the buyout "blood money"?

It was blood money before that let’s be honest.

Medicine’s Worst-Paying Specialty Is Luring Billions From Wall Street

Private equity, pharmacy chains and health insurers are vying for the doctors at the gates of the health-care system

www.bloomberg.com

PE getting into PCP practices now. I’m sure that’ll be great for the day to day physician or the army of midlevels that they have to blindly sign off on.

 

[dannyboy1]

USAP took a lower rate with United to make their numbers look better so the private equity can flip shares yet again. Some MDs may sell their shares too. So a win for PE and any old guys who sold out. A huge loss for anyone who got shares later or is a junior partner.

USAP doesn’t care. It’s not about the physicians or future. It’s about return

This law is the death of private equity groups. Rates will drop and there will be no way for Private equity to get a return without cutting salaries-which then they won’t have enough staff. Will take 5 years but these groups are done.

There will only be small medium sized private groups or more likely all anesthesia will be hospital employed

Maybe. Either way, not good for us. If Hospital employed the hospital suddenly becomes very cost conscious. Maybe doesn’t offer anesthesia for those cases that don’t really need it (IR,cath lab, lots of podiatry cases) they also become more tolerant of telling the surgeon to wait his turn. Can’t just have anesthesia wherever and whenever you want. Demand for our services decrease and so do our salaries….

 

[ambiturner]

Maybe. Either way, not good for us. If Hospital employed the hospital suddenly becomes very cost conscious. Maybe doesn’t offer anesthesia for those cases that don’t really need it (IR,cath lab, lots of podiatry cases) they also become more tolerant of telling the surgeon to wait his turn. Can’t just have anesthesia wherever and whenever you want. Demand for our services decrease and so do our salaries….

My experience going from private to hospital employed is that they try to get MORE services since your salary is already a sunk cost and every extra case you do goes in their pocket. The administrators call this ‘strategic alignment of key service lines’. Think expanded hours for add-ons, imaging, IR…

But your point stands, whether it’s less dollars and the same hours or the same dollars and more hours it’s a decrease in pay.

 

[dannyboy1]

My experience going from private to hospital employed is that they try to get MORE services since your salary is already a sunk cost and every extra case you do goes in their pocket. The administrators call this ‘strategic alignment of key service lines’. Think expanded hours for add-ons, imaging, IR…

But your point stands, whether it’s less dollars and the same hours or the same dollars and more hours it’s a decrease in pay.

If you are dumb enough to sign a contract without set hours, then yes, you will be abused…

 

[secretasianman]

U think the crnas are willing to work for nothing? I think not.

 

[anbuitachi]

U think the crnas are willing to work for nothing? I think not.

i think crna will be willing to work for icu nurse pay , most crnas i know like OR work than ICU work

 

[ambiturner]

i think crna will be willing to work for icu nurse pay , most crnas i know like OR work than ICU work

Most crnas graduate with $100-200k debt, so unless that gets fixed they’re going to expect a premium wage (not unlike American doctors over their European counterparts).

The more I think about it the more I think employment is the future for most, where revenue is not the determinant of pay, just like if you were an employed engineer or nurse or HR manager etc. Anesthesia will just be another coat center that gets paid out of massive facility fees and brings a token amount in. At least in pediatrics many employed surgeons are paid like this too.

 

[anbuitachi]

Most crnas graduate with $100-200k debt, so unless that gets fixed they’re going to expect a premium wage (not unlike American doctors over their European counterparts).

The more I think about it the more I think employment is the future for most, where revenue is not the determinant of pay, just like if you were an employed engineer or nurse or HR manager etc. Anesthesia will just be another coat center that gets paid out of massive facility fees and brings a token amount in. At least in pediatrics many employed surgeons are paid like this too.

i read avg crna school cost about low 100s. dont know how much savings they have since they all have prior work experience. not too bad for 2.5 years. more time to pay i t off

 

[Luvssjeter]

It is looking very grim for anesthesia. You can get in network rates through an IPA if your independent or a small group but they are not great and you have to pay to use their rates some where around 3-5k per year. If you out source your billing that’s another 5-7%. The few claims I’ve heard have been horrible…14unit lumbar lami…qpa (qualifying payment amount) from UHC $410 bucks of which about $60 was the patients portion and so actual payment was $350. 410/14 units = $30/unit homie. Now how can this be the median in network rate?? Arbitrator doesn’t have to make sure it’s correct or not, as per the law, not their job. But it’s the doctors job to prove why they deserve more than this supposed median in network rate…Also, good luck collecting your $60 from a patient that is probably never going to see you again. So really $350/14 units =$25/unit.
Not trying to fear monger but more get insight on what others are seeing or thinking.

This anesthesiologist seems to explain things pretty well for those interested though this was filmed prior to the interim rules becoming final. Not that anything changed.

 

[GassYous]

It is looking very grim for anesthesia. You can get in network rates through an IPA if your independent or a small group but they are not great and you have to pay to use their rates some where around 3-5k per year. If you out source your billing that’s another 5-7%. The few claims I’ve heard have been horrifying….14unit lumbar lami…qpa (qualifying payment amount) from UHC $410 bucks of which about $60 was the patients portion and so actual payment was $350. 410/14 units = $30/unit homie. Now how can this be the median in network rate?? Arbitrator doesn’t have to make sure it’s correct or not, as per the law, not their job. But it’s the doctors job to prove why they deserve more than this supposed median in network rate…Also, good luck collecting your $60 from a patient that is probably never going to see you again. So really $350/14 units =$25/unit.

I took my daughter for her 15 month well child visit. BCBS paid my pediatrician over $400 for a well child visit, granted it included vaccines. My point is not that she doesn’t deserve the $400. She’s a fantastic pediatrician and she deserves every cent but she saw my daughter for 15 min….but an 80min lumbar lami is getting reimbursed less than a well child visit….and we can’t see 20 kids in a day…maybe we can churn out 4-6 lumbar lami’s and let’s hope they are all private insurance….There are no words.

Not trying to fear monger but more get insight on what others are seeing or thinking. This anesthesiologist seems explains things pretty well for those interested though this was filmed prior to the interim rules becoming final.

How can a lumbar lami be 14 units? 11 start up and it is at least 3 units just to sleep, turn and wake up

 

[Luvssjeter]

How can a lumbar lami be 14 units? 11 start up and it is at least 3 units just to sleep, turn and wake up

Good question. I didn’t do this case but this was from a pretty reliable source who actually sees all his EOBS.

Anyway regardless, I just looked up the code for a “simple” lumbar lami in the ASA relative value guide….00630 -8 units + time 80min/15= 5.3 units. Billed units 8+6 (time was rounded up), assuming pt was ASA 2 so no ASA modifier=14 units. Make sense to me. What code would you bill for a lumbar lami?

You can bill 00670 if it’s 3 vertebral bodies so L2-5, and that is 13 units+ time. If your codes don’t match the hospitals or surgeons the claim has high chance for denial and then you need to submit medical records because they won’t pay you till they get them.

I guess this was 1 or 2 levels hence 00630.

 

[mtbtx]

This law is meant to put everything on the QPA as a way to pound down the private equity unit rates and make anesthesia more cost affordable, aka lower pay. This is all under the guise of surprise billing, which most anesthesiologists are against but was exploited by PE groups. The real question is, what is our time actually worth? Billing in anesthesia is actually simple. You get a lump sump for going to sleep (base units) plus paid for time (1 unit per 15 minutes) multiplied by a unit rate. Insurance companies want to keep it feeling complex and now keep everyone guessing with this new QPA.

Here is a crazy idea- why not cut out the QPA and insurance companies altogether and post transparent cash "take it or leave it" prices? Ironically, this could be done directly through the protection of the No Surprises Act by getting patient consent for going out of network and providing a "good faith estimate" (GFE) which would be easy to do. This would work for any elective/scheduled case, the only logistical problem is getting the patient's consent before surgery and providing the GFE. You would still take a hit via CMS cases and emergency "forced" in-network QPA cases which will likely be close to medicare soon. Providing transparent pricing would establish what an anesthesiologist's time/effort is actually worth and the ball would be in the insurance companies' court to pay it.

Bottom line is this- we are underpaid for what we do. I think if there were more price transparency and education, patients would be on our side and expect their insurance company to pay. When I do cash cases at 150% the rate of insurance companies most patients still think they are getting a bargain!

 

[coffeebythelake]

Anesthesia will just get more stipends to run. Hospital and facility fees are still ridiculously high. And hospitals don't make money when ORs are idle.

 

[lane]

This law is meant to put everything on the QPA as a way to pound down the private equity unit rates and make anesthesia more cost affordable, aka lower pay. This is all under the guise of surprise billing, which most anesthesiologists are against but was exploited by PE groups.

This is silly. It affects everyone, not just PE groups. It’s meant to drive down your rates to CMS rates so the insurance carriers can further maximize their already historic profits.
The PE groups are the only ones with scale and resources to fight the carriers and their lobbyists.

 

[Drägerman]

It is looking very grim for anesthesia. You can get in network rates through an IPA if your independent or a small group but they are not great and you have to pay to use their rates some where around 3-5k per year. If you out source your billing that’s another 5-7%. The few claims I’ve heard have been horrible…14unit lumbar lami…qpa (qualifying payment amount) from UHC $410 bucks of which about $60 was the patients portion and so actual payment was $350. 410/14 units = $30/unit homie. Now how can this be the median in network rate?? Arbitrator doesn’t have to make sure it’s correct or not, as per the law, not their job. But it’s the doctors job to prove why they deserve more than this supposed median in network rate…Also, good luck collecting your $60 from a patient that is probably never going to see you again. So really $350/14 units =$25/unit.
Not trying to fear monger but more get insight on what others are seeing or thinking.

This anesthesiologist seems to explain things pretty well for those interested though this was filmed prior to the interim rules becoming final. Not that anything changed.

This is a must watch video

 

[DirtDocMD]

This law is meant to put everything on the QPA as a way to pound down the private equity unit rates and make anesthesia more cost affordable, aka lower pay. This is all under the guise of surprise billing, which most anesthesiologists are against but was exploited by PE groups. The real question is, what is our time actually worth? Billing in anesthesia is actually simple. You get a lump sump for going to sleep (base units) plus paid for time (1 unit per 15 minutes) multiplied by a unit rate. Insurance companies want to keep it feeling complex and now keep everyone guessing with this new QPA.

Here is a crazy idea- why not cut out the QPA and insurance companies altogether and post transparent cash "take it or leave it" prices? Ironically, this could be done directly through the protection of the No Surprises Act by getting patient consent for going out of network and providing a "good faith estimate" (GFE) which would be easy to do. This would work for any elective/scheduled case, the only logistical problem is getting the patient's consent before surgery and providing the GFE. You would still take a hit via CMS cases and emergency "forced" in-network QPA cases which will likely be close to medicare soon. Providing transparent pricing would establish what an anesthesiologist's time/effort is actually worth and the ball would be in the insurance companies' court to pay it.

Bottom line is this- we are underpaid for what we do. I think if there were more price transparency and education, patients would be on our side and expect their insurance company to pay. When I do cash cases at 150% the rate of insurance companies most patients still think they are getting a bargain!

Exactly. Most of these cases (elective/scheduled), should be paid UP FRONT, then let the patients/hospitals duke it out with the insurance companies to get their money.

Since the posting of these cases is out of Anesthesiologists’ control, and done by the HOSPITAL, groups (without stipends) should start “contractually requiring” the hospital to make good on the payment (if not given up front) within 30 days, and let THEM fight these battles or wait 6-12 months for payment.

 

[Endee]

We need more people to copy the Surgery Center of OK model and launch free standing, cash pay surgery centers, untethered to any hospital system, insurance carrier, or private equity firm.

 

[nimbus]

It is looking very grim for anesthesia. You can get in network rates through an IPA if your independent or a small group but they are not great and you have to pay to use their rates some where around 3-5k per year. If you out source your billing that’s another 5-7%. The few claims I’ve heard have been horrible…14unit lumbar lami…qpa (qualifying payment amount) from UHC $410 bucks of which about $60 was the patients portion and so actual payment was $350. 410/14 units = $30/unit homie. Now how can this be the median in network rate?? Arbitrator doesn’t have to make sure it’s correct or not, as per the law, not their job. But it’s the doctors job to prove why they deserve more than this supposed median in network rate…Also, good luck collecting your $60 from a patient that is probably never going to see you again. So really $350/14 units =$25/unit.
Not trying to fear monger but more get insight on what others are seeing or thinking.

This anesthesiologist seems to explain things pretty well for those interested though this was filmed prior to the interim rules becoming final. Not that anything changed.

That’s pretty unbelievable. I have a HDHP with UHC. In December, I had a 6hr, ~45 unit procedure with an in-network provider. This is what they paid.

 

[Luvssjeter]

That’s pretty unbelievable. I have a HDHP with UHC. In December, I had a 6hr, ~45 unit procedure with an in-network provider. This is what they paid.


View attachment 350090

Unbelievable, I’m not understanding? The in network rate here is about $150/unit. Is this group still in UHC’s network? Maybe they are about to get the boot. Maybe UHC will boot the doctors over the next two years. I don’t know.
USAP, from the rumors, was getting high 100’s per unit and had to resign significantly lower.

Like I said this thread was not created to cause fear but get input and insight from other anesthesiologists around the country.

And cash pay would be tricky…many times anesthesiologists hold their claims so the patients meet their deductible through the facility and surgeon so we aren’t the ones “charging” the patients. Also, our charged amounts are pretty high ie 10k for 6hr surgery (see above post) probably more than the surgeon’s bill. If you ask the patients for cash pay because you’re out of network a few things could happen. 1. They are okay with it and pay because they understand the importance of a board certified anesthesiologists. 2. They complain to surgeon and cancel the surgery because they can’t pay 3. Go to adminsitration and ask why their anesthesia group isn’t in network. 4. Call insurance and ask them which anesthesiologists are in their network or why there are so few…all of these have pros and cons. This is a lot more feasible for larger groups since harder to bully or replace as opposed to small groups or independents. Just my 2 cents.

 

[mtbtx]

This is silly. It affects everyone, not just PE groups. It’s meant to drive down your rates to CMS rates so the insurance carriers can further maximize their already historic profits.
The PE groups are the only ones with scale and resources to fight the carriers and their lobbyists.

Obviously it affects everyone. My point is that the NSA is the direct result of PE consolidation and subsequent billing shenanigans. In my market PE groups are trying to get 2-3x the “QPA”, and have exploited balance billing since acquiring practices. In fact, many small-medium sized groups may see a paradoxical increase in their unit rate by being buoyed by the PE groups. This is assuming that the QPA is transparent and shared publicly, which of course it will not be. Again, I think price transparency is the antidote here.

 

[mtbtx]

Exactly. Most of these cases (elective/scheduled), should be paid UP FRONT, then let the patients/hospitals duke it out with the insurance companies to get their money.

Since the posting of these cases is out of Anesthesiologists’ control, and done by the HOSPITAL, groups (without stipends) should start “contractually requiring” the hospital to make good on the payment (if not given up front) within 30 days, and let THEM fight these battles or wait 6-12 months for payment.

Seriously, why can't we do this? Anesthesia bills are some of the simplest and least complex in medicine. If everyone posted a 1)go-to-sleep charge and a 2)time charge, every bill would be 100% predictable (with time being the only variable). It would be no different than a plumber's quote: price to start the job, and hourly rate to finish the job.

 

[mtbtx]

Unbelievable, I’m not understanding? The in network rate here is about $150/unit. Is this group still in UHC’s network? Maybe they are about to get the boot. Maybe UHC will boot the doctors over the next two years. I don’t know.
USAP, from the rumors, was getting high 100’s per unit and had to resign significantly lower.

Like I said this thread was not created to cause fear but get input and insight from other anesthesiologists around the country.

And cash pay would be tricky…many times anesthesiologists hold their claims so the patients meet their deductible through the facility and surgeon so we aren’t the ones “charging” the patients. Also, our charged amounts are pretty high ie 10k for 6hr surgery (see above post) probably more than the surgeon’s bill. If you ask the patients for cash pay because you’re out of network a few things could happen. 1. They are okay with it and pay because they understand the importance of a board certified anesthesiologists. 2. They complain to surgeon and cancel the surgery because they can’t pay 3. Go to adminsitration and ask why their anesthesia group isn’t in network. 4. Call insurance and ask them which anesthesiologists are in their network or why there are so few…all of these have pros and cons. This is a lot more feasible for larger groups since harder to bully or replace as opposed to small groups or independents. Just my 2 cents.

Good arguments against cash pay. I'm not proposing we squeeze patients directly for cash. However, price transparency would cut through the QPA issue by clearly demonstrating what anesthesia service is worth. By going public with these numbers it would help negotiate against the QPA, private payers and CMS.

 

[nimbus]

Unbelievable, I’m not understanding? The in network rate here is about $150/unit. Is this group still in UHC’s network? Maybe they are about to get the boot. Maybe UHC will boot the doctors over the next two years. I don’t know.
USAP, from the rumors, was getting high 100’s per unit and had to resign significantly lower.

Like I said this thread was not created to cause fear but get input and insight from other anesthesiologists around the country.

And cash pay would be tricky…many times anesthesiologists hold their claims so the patients meet their deductible through the facility and surgeon so we aren’t the ones “charging” the patients. Also, our charged amounts are pretty high ie 10k for 6hr surgery (see above post) probably more than the surgeon’s bill. If you ask the patients for cash pay because you’re out of network a few things could happen. 1. They are okay with it and pay because they understand the importance of a board certified anesthesiologists. 2. They complain to surgeon and cancel the surgery because they can’t pay 3. Go to adminsitration and ask why their anesthesia group isn’t in network. 4. Call insurance and ask them which anesthesiologists are in their network or why there are so few…all of these have pros and cons. This is a lot more feasible for larger groups since harder to bully or replace as opposed to small groups or independents. Just my 2 cents.

Yes. As far as I know they are still in-network. It’s an academic regional referral center (one of the Univ of Ca hospitals). Not PE. Surgeon received about $10k for the procedure. (Both surgeon and anesthesiologist are actually salaried but the amounts described are for their professional fees). Total hospital charges were $290k. The hospital accepted about $70k from the insurance company. I had already met my deductible earlier in the year and paid nothing out of pocket.

 

[nimbus]

Seriously, why can't we do this? Anesthesia bills are some of the simplest and least complex in medicine. If everyone posted a 1)go-to-sleep charge and a 2)time charge, every bill would be 100% predictable (with time being the only variable). It would be no different than a plumber's quote: price to start the job, and hourly rate to finish the job.

At plastic surgery offices, we charge $X for the first hour of anesthesia and $Y for every subsequent hour.

 

[mtbtx]

Yes. As far as I know they are still in-network. It’s an academic regional referral center (one of the Univ of Ca hospitals). Not PE. Surgeon received about $10k for the procedure. (Both surgeon and anesthesiologist are actually salaried but the amounts described are for their professional fees). Total hospital charges were $277k. The hospital accepted about $80k from the insurance company. I had already met my deductible earlier in the year and paid nothing out of pocket.

Congrats on the new liver?

 

[nimbus]

Congrats on the new liver?

Not quite . It was actually a 3day total hospital stay including 1 night in ICU. Liver must be over $1mil.

 

[mtbtx]

At plastic surgery offices, we charge $X for the first hour of anesthesia and $Y for every subsequent hour.

Same; I'm always pleasantly surprised how willing patients are to pay cash when it is transparent and fully explained upfront. Granted, different population than with most other surgeries. Interesting that the NSA provides a perfectly legal and clear path to bill out of network now that is similar to current cash plastic practices.