UHC Reimbursement cuts

[king22]

Has anyone else received notice from UHC about reimbursement cuts? It looks like they are cutting across the board by about 10-20% for commercial plans.

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[heybrother]

Our commercial plans with them are sub-Medicare (80%) and based on 2019 or 2020 - as such we derived no benefit from the E&M change.

I wondered for awhile if they are actually engaging in a market moving plan to try and "battle" balance billing. Essentially they intend to drive down the average reimbursement everywhere so in the future they can argue elevated balance billing rates are unfair because the "normal" rate is low when in fact they artificially drove down the rates by paying nothing.

 

[king22]

Our commercial plans with them are sub-Medicare (80%) and based on 2019 or 2020 - as such we derived no benefit from the E&M change.

I wondered for awhile if they are actually engaging in a market moving plan to try and "battle" balance billing. Essentially they intend to drive down the average reimbursement everywhere so in the future they can argue elevated balance billing rates are unfair because the "normal" rate is low when in fact they artificially drove down the rates by paying nothing.

I wouldn't be surprised. Our commercial rates dropped from 60% to 50% of Medicare in one of my offices (the other office I'm in an IPA so I'm somewhat protected).

 

[air bud]

I wouldn't be surprised. Our commercial rates dropped from 60% to 50% of Medicare in one of my offices (the other office I'm in an IPA so I'm somewhat protected).

50 percent of Medicare? Holy crap. I hate seeing Medicare because pays way less than all my commercial plans

 

[king22]

50 percent of Medicare? Holy crap. I hate seeing Medicare because pays way less than all my commercial plans

NY sucks when it comes to commercial rates. My managed Medicaid plans now pay significantly more than most of my commercial plans.

 

[heybrother]

I wouldn't be surprised. Our commercial rates dropped from 60% to 50% of Medicare in one of my offices (the other office I'm in an IPA so I'm somewhat protected).

I don't understand how anyone survives on those rates. You can't operate on them. Its free every single time.

 

[king22]

I don't understand how anyone survives on those rates. You can't operate on them. Its free every single time.

You honestly need to get "creative". We're lucky enough that the majority of our UHC is the NYS employee insurance plan which covers custom foot orthotics at abut $400/pair every year. You can guess that there is a strong incentive to make as many orthotics as you can.

But we're partially to blame for this. We keep taking these hits and still choose to participate in these plans. If it was entirely up to me, I'd drop these plans immediately and go out of network (most have out of network benefits).

 

[king22]

I don't understand how anyone survives on those rates. You can't operate on them. Its free every single time.

I happened to email UHCs network management team regarding their reasoning for these decreases. I got one hell of a nasty email in response a few minutes ago (pretty much saying that they have the power to do this because this is in my contract. I never quested whether they had the power to do this, only their reasoning for why they did this)

 

[SouthPod7]

Is this something that joining a PHO (physician health/hospital organization) would help with? That way you can negotiate reimbursement rates as a group?

 

[king22]

Is this something that joining a PHO (physician health/hospital organization) would help with? That way you can negotiate reimbursement rates as a group?

Yes. I'm a member of an IPA (Independent Physician Association) which has helped me significantly with my contracts. The only problem is that for one to join at a new practice location, all doctors at the practice location must be participating in the IPA.

 

[dtrack22]

I wouldn't be surprised. Our commercial rates dropped from 60% to 50% of Medicare in one of my offices (the other office I'm in an IPA so I'm somewhat protected).

Dang. Medicaid in our state is something like 78% of Medicare. I will never criticize anyone from NY from playing the out of network game again. Well, except for that lady podiatrist who billed $178k for some in office hammertoe procedures…that’s excessive

 

[king22]

Dang. Medicaid in our state is something like 78% of Medicare. I will never criticize anyone from NY from playing the out of network game again. Well, except for that lady podiatrist who billed $178k for some in office hammertoe procedures…that’s excessive

Most of my managed Medicaid plans pay between 70-90% of medicare.

Over the past year I've been slowly dropping insurance plans. It started with Aetna (after i realized that 80% of my aetna patient's were medicare advantage and pretty much all had comprehensive out of network benefits). I'm thinking UHC is going to be next. I was out of network for awhile at another office with UHC and the state plan (which accounts for about 75% of all my UHC patients) paid around 120% of medicare (as well at about $800 for a pair of custom orthotics).

 

[G0dFather]

that lady podiatrist who billed $178k for some in office hammertoe procedures

That was criminal even though she was charging for a facility fee

I was out of network for awhile at another office with UHC and the state plan

I am out of net on NYSHIP it makes the most sense now with all the games they play when your innetwork, biggest issue we have is the 1500 deductible that comes with the plan many times they come in and its mostly met which tells me that many other docs besides pods are making the same move as well ... soon they will find a way to rock us with that too

 

[heybrother]

This is interim so it may change but I can't help but feel this supports my point. They drive down the presumably in network and out of network rates so that when surprise billing occurs the out of network rate is the starting point. Which is a fabulous process because the hospital or physician presumably in question had already decided that the in-network rates were terrible which was why they were not accepting it to begin with.

 

[king22]

That was criminal even though she was charging for a facility fee

I am out of net on NYSHIP it makes the most sense now with all the games they play when your innetwork, biggest issue we have is the 1500 deductible that comes with the plan many times they come in and its mostly met which tells me that many other docs besides pods are making the same move as well ... soon they will find a way to rock us with that too

I'm seriously considering going out of network with NYSHIP at this point. It was pretty bad when rates were 60% of Medicare. 50% is ridiculous

Though it's still better than the crappy $34 they used to pay for a 99213 (in network) up until 2018.

 

[DYK343]

I'm seriously considering going out of network with NYSHIP at this point. It was pretty bad when rates were 60% of Medicare. 50% is ridiculous

Though it's still better than the crappy $34 they used to pay for a 99213 (in network) up until 2018.

In a high cost of living state? Crazy.

 

[DYK343]

$178k for some in office hammertoe procedures…that’s excessive

Was this in PMNews or something? I missed this...

 

[heybrother]

Was this in PMNews or something? I missed this...

Yeah. It's the lady who runs the aesthetics institute. The insurance company wrote a check for like $178,000 or whatever the amount was above but instead of sending it to the doctor they sent it to the patients address. When the patient saw how much the doctor was getting they were shocked and called the insurance company back. Then the doctor started desperately calling the patient demanding they send the check. Something ridiculous like that. You can definitely find it online.

 

[air bud]

I'm seriously considering going out of network with NYSHIP at this point. It was pretty bad when rates were 60% of Medicare. 50% is ridiculous

Though it's still better than the crappy $34 they used to pay for a 99213 (in network) up until 2018.

There is zero point in practicing medicine getting paid 34 bucks for a 99213. Regardless of how many 800 dollar orthotics you can scam insurance our of

 

[GreenHousePub]

Yeah. It's the lady who runs the aesthetics institute. The insurance company wrote a check for like $178,000 or whatever the amount was above but instead of sending it to the doctor they sent it to the patients address. When the patient saw how much the doctor was getting they were shocked and called the insurance company back. Then the doctor started desperately calling the patient demanding they send the check. Something ridiculous like that. You can definitely find it online.

Don't forget when they charged the patient 7k up front as well.

 

[king22]

There is zero point in practicing medicine getting paid 34 bucks for a 99213. Regardless of how many 800 dollar orthotics you can scam insurance our of

I agree with your first sentence. I talked to my employer today about going out of network with UHC-Empire Plan and was quickly rebuked. I was told that we have see a lot of patient's with that insurance and we would probably lose the vast majority of them (I completely disagree).

As for the second sentence, I take a bit of issue with it. There is no "scamming" going on. I follow the coverage guidelines that are set forth by the plan. This plan happens to have very generous orthotic benefits- no authorizations, no pre-cert, almost any msk code accepted. I do not make them for every patient that walks through the door. If their problem can be helped by one, I make one; if it can't, I don't.

 

[air bud]

I agree with your first sentence. I talked to my employer today about going out of network with UHC-Empire Plan and was quickly rebuked. I was told that we have see a lot of patient's with that insurance and we would probably lose the vast majority of them (I completely disagree).

As for the second sentence, I take a bit of issue with it. There is no "scamming" going on. I follow the coverage guidelines that are set forth by the plan. This plan happens to have very generous orthotic benefits- no authorizations, no pre-cert, almost any msk code accepted. I do not make them for every patient that walks through the door. If their problem can be helped by one, I make one; if it can't, I don't.

ok, scam is wrong word. I know, when it comes to amnio I am just following medicare guidelines...

 

[king22]

On a related note, I have discovered that UHC-MA has been paying the other doctors at my practice the facility rates for E&M codes- when the pos is the office.

UHC is a joke

 

[G0dFather]

There is zero point in practicing medicine getting paid 34 bucks for a 99213. Regardless of how many 800 dollar orthotics you can scam insurance our of

Ins companies dont make it a fair playing field.