Readers share their two cents on $4.07 insurance payment

In his recent blog post “My $4.07 check: A sign of the times,” Henry Rosevear, MD, shared how, after managing a patient with an obstructing stone and billing $1,332.25 for his services, he received a check from the Colorado Indigent Care Program, the patient’s insurer, for $4.07. His blog post prompted a wave of comments, commiseration, and suggestions. These comments have been compiled below. If you would like to share your opinion on the topic or if you have had a similar experience, please provide your feedback by posting a comment in the box below, or by sending the editors an email at UT@advanstar.com. 

I am a urologist who is part of a 20-urologist group (soon to become up to 70). I have a mixed practice due to two office locations. One office is in an affluent area and the second is in a blue collar town. Our “pod” of five physicians work in four hospitals. Two hospitals are in affluent areas, one hospital is in a blue collar town, and one hospital is in a poor inner city. We see many un-insured and Medicaid level patients mostly within the inner city hospital. However, we are seeing more un-insured and Medicaid patients travelling to the more affluent area hospitals for their health care.

Two of these hospitals provide a stipend for covering the Emergency Room and hospital consults. We just started this stipend at a third hospital due to increasing demand of un-insured and Medicaid patients and on-call responsibilities. We have calculated the stipend and it covers very basic urologic skills such as Foley placements, stent insertions, simple ureteroscopies, and mildly complex consults. But, it does not cover patients who require detailed management such as trauma, advanced cancers, or complicated stones.

Here's the way I see it from 13 years of practice.... the hospitals should be providing private practice physicians financial compensation to work at the hospital and cover un-insured or Medicaid patients. We should be compensated for leaving office hours (of paying patients) or spending time away from family to do a consult or operate. The days when a physician was paid handsomely for surgery and one could just "write-off" the pro bono work are gone.

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My question for you is how much the hospital was paid for the patient you stented for $4.07? Did the hospital receive $1,900 from the Medicaid program and then $2,500 from state aid? If the answer is yes, then the hospital should be passing the payment to the providers.

Can you have a conversation with your hospital about such a stipend?

Another thought is that hospitals have endowments, fundraisers, and philanthropic support. Where does that money go? Does it go to help the administrators or the physicians who bring business to the hospital? Private practitioners cannot ethically fundraise for their office or personal gain.

I see one dilemma. What if the hospitals hire a staff urologist to compete with the private physicians? What if the hospitals restrict patient flow to the private physician? Will that prevent the private physicians from maintaining a healthy/vibrant practice?

To my understanding, a single payer system sort of exists: Medicare. But, it covers the physicians a little bit more respectfully than the uninsured or Medicaid patients.

More than happy to talk some more.

Marc A. Greenstein, DO

Next: "There is no answer that will make doctors happy."

There is no answer that will make doctors happy.

Patients will be happy with nationalized health care, until, like in England or Canada, they have to wait up to a year for an elective surgical case that is currently done in America within a few days.

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Doctors who are hospital employees will not notice any difference, they are already adjusted to having incomprehensible rules shoved down their throats, and they do not have to worry about mundane issues such as "getting paid.”

Unfortunately, YOU are a dinosaur. You are amongst the last independent paid doctors left in America, and your days are dwindling. You cannot exist, as you haven't the power to fight Obamacare, and fight federal mandates, and fight "restricted narrow physician provider lists,” and most importantly, you do not have the ability to fight dwindling reimbursements and ever higher copayments and deductibles.

Your surgical services are still needed, but the primary activity and raison d'etre of your urology team is that of "bill collector.” Your firm has been turned into a collection agency that just happens to employ urologists. Better get used to getting paid peanuts for your many years of practice, of experience, and of continued training and continued recertification.

I'm 64 years old and I retired 1 year ago, due to severely falling reimbursements.

It's a shame, as I could have gone on for another 10 years or more. I miss the fun of surgery and the wonderful interactions with patients and colleagues. But I don't see the point in spending down your retirement assets, to keep the ship afloat.

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If I were you, I would spend exorbitantly on funding your retirement assets and programs, so you have the freedom to quit when the frustration becomes overwhelming.

Charlie Feinstein, MD

Next: "It’s simple. No urologist should sign up for another insurance contract."

It’s simple. No urologist should sign up for another insurance contract. The ones that are contracted, should quit the plan. Resign. Once we are all out-of-network, we hold the cards. Then we can go as a group of urologists and negotiate nationwide with all insurers. Each CPT is then paid at a rate that makes most of us happy. That fee is likely slightly more than [the] charge that we would give our cash-paying patients.

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An example is your ureteroscopy case. We bill $6,000 for that. Out of network might pay you $5,000. Contracted rate is under $1,000. Medicaid is $275 if you are lucky. Cash patients are usually let off cheap at $1,000. If we all agree that the going rate is $1,750 (whether we use a laser, or EHL, or basket), done deal, check is in the mail, I guarantee 95% of urologists sign that contract with a smile. There is no longer a question of if it will pay and if so, what is the allowed or mystery negotiated amount (since you never got to see a fee schedule when you signed the last contract with the insurer). You do this for every urology CPT. Query us through our AUA ID. Have us look at the fee schedule that the AUA has negotiated on our behalf. Have us vote on it. Line by line, code by code. We offer the price we think it should be (if the negotiated amount is too low) and send it back for another round until the number makes 80% of participating urologists happy.

Some out of network guys may not sign on as geographically, they can stay out and continue to rake-it-in with reimbursements much higher than most are willing to accept. Can’t make them join, but many would do so, just to not to have to argue with insurers and hire extra billers and lawyers and fight with patients who keep the check sent to them by insurance companies.

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Think we could do it? I bet rates would be lower than the Usual and Customary we normally bill. Most of us are reasonable. Let me know when you have a team of doctors at the highest levels of urology with the ears of the insurance companies and politicians at their disposal and we will get the ball rolling. I bet 80% of urologists would even do the under-insured stuff (Medicaid) for 50% of the full rate and self-pay (physicians guaranteed pay by state or hospital networks for patients with no insurance or money) at 35%.

Franklin Margolis, MD

Next: "Even if they don't have insurance, a simple gesture of gratitude or card of thanks would be nice."

This scenario happens all too frequently. Working on the outskirts of a major metropolitan city, it amazes me how many people bring family members from foreign countries to the US for care. Once they enter the system by arriving in ER's, they can't be refused treatment. It is an opportunity for our urology residents to learn but concept of entitlement becomes meaningless when this care is free. I don't think people would expect this from their auto mechanics, plumbers, tree service people, etc.

In these cases, it is RARE that I ever get a thank you from people with no insurance. I guess they don't realize (or simply don't care) that we provide this care gratis or for minimal reimbursement. Even if they don't have insurance, a simple gesture of gratitude or card of thanks would be nice.

Anonymous

I recently hired a small town plumber to fix my obstructed plumbing. When I asked his price, it was $75/hr. When I complained that I only made $2/hr as a urologist he said: "So did I when I was a urologist."

Oh well. My take on the PSA situation is that it is related to money and not scientific information. At the risk of sounding like a conspiracy activist: it seems to be age and gender biased. Breast cancer screening and colon cancer screening are also on the gender/age bias horizon.

Thanks for your clear headed writing.

James F. Reeves, MD (retired urologist)

More from Dr. Rosevear:

VA Choice: Not what the doctor ordered

Is bigger better in today’s urology practice?

My six-digit mistake with a new health insurer

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