Transcript Sample Title Page

Making Cents of Reimbursements
Chris Sipe, MD
Fertility 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
$$
Nurses/Staff
Rent/Utilities
Equipment
Supplies
Marketing
Malpractice
$
Private Practice Reimbursement- Insurance
$
$$
Nurses/Staff
Rent/Utilities
Equipment
Supplies
Marketing
$
Malpractice
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:
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–
–
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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
Research Grants
Rent/Utilities
Equipment
Supplies
Marketing
Malpractice
Coders/Admin
$
Residents
More Admin
Fellows
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 attention
Any Questions?
[email protected]