Re: Physician sets his own 'capitation'

[Steve Verno]

Nope, just have too much time on my hands in between dieting, walking, keeping the wife happy, and watching ghosthunters or scariest places on earth, Surivor or My name is Earl.  Just biding my time until Star Trek 11.

Started my cardiac diet at 320 lbs,  now at 311.  Want to get down to 180 again.   

[Steve Verno]

Thats one of my many projects.  Im doing one on medical billing terminology for you. 

[Steve Verno]

they want to close any doctor down where it interferes with the insurance companies.   Our elected officials are paid big bucks or their relatives are paid big bucks as consultants.  They also have high priced lobbiests working for the insurance companies. 

The insurance company wants the same deals.  We'll pay the provider $79 per month to see our patients.  Along comes a provider and gets pressure to contract. he doesnt like the $79 per month fee.  The insurance company says that is all we pay providers in your area.  So the doctor says no to the contract.

Here a Tampa paper published an article regarding a congressperson getting paid 80,000 as a consultant to the HMOs. THis congressperson was in charge of Florida Healthcare Laws. YOu arent going to lose $80,000 by voting laws against the HMOs paying you.

So, we'll put nice doctors wanting to do some good, out of business.  THis forces them to sign terible contracts with the insurance companies or has the employer sign up for expensive healh care benefits. 

YUp, put the humanitarian out of business. 

[Danni R.]

May be (where doctors can set their own fees) has to do with what's acceptable and common in that area. I know that there are certain guideline, and standards as to how much a doctor can charge, even though they are able to set their own fees.

[Steve Verno]

hi Michelle

I know its for uninsured.  Ive seen patients do many things.  One of my providers has the patient sign an insurance affidavit. We got many patients sign the affidavit signifying they have NO health insurance coverage or they are "uninsured".  They get the bill and we get a letter from an HMO lawyer saying we're in violation of New York Law by billing a NY HMO patient or we'll get a nasty letter from the Agency for Healthcare Regulation saying our provider may lose his license and face sanctions because we sent a Florida Medicaid patient to our debt collection agency. We send the affidavit showing uninsured status.  The affidavit was developed by the practice lawyer.  The patients know they have Medicaid but withhold that info from the doctor.  I have seen the insured patient sign the affidavit signifying uninsured status and then ask for a discount. They do pay.  They ask for a receipt showing full charges.  He'll scan the document removing the discounted payment and then altering the document to show payment of the full charges.  They send this to the insurance company for reimbursement.  Next, we get the letter from the Office of Insurance Regulation or the HMO lawyer saying we may have violated FS 641.3154 by billing the member. we are ordered to return the payment. I send a copy of the affidavit and copy of the true statement showing the discount.  The claim per lawyer letter is denied for timely filing and the letter denying the claim says we are prohibited from billing their member.  We do anyway showing FS specifically says the member cant be biled as long as the HMO accept liability for the claim.  Denying for timely filing is not accepting liability for the claim.  We also have the affidavit showing uninsured status.  Ive seen and heard patients do many crazy things over the years. 

We had one patient tell us to bill Medicare.  When he was billed for the deducible He called, yelling we screwed up. We should have billed the VA.  We sent a claim to the VA.  They denied for no authorization.  Next we were to bill his auto insurance as this was finally revealed as an auto accident.  They applied to the deductible.  Next was the we screwed up call and then came a we screwed up letter.  The letter says to bill Tricare.  We did.  They denied for TPL.  Next came the we screwed up letter.  It was finalized by his visiting our office with a gun. Next came the police.  He was adamant we screwed up so he said he didn't have to pay.  Finally we got a letter from his lawyer regarding his being denied a home loan because of an entry on his credit report.  Our lawyer responded.  Never heard anything more. I think we can write a book of the many things that we have see happen.

[Danni R.]

I have seen a couple ads from a local dental clinic that charges a set fee, but I never paid it much attention. I believe it's for children. Interesting concept though. Sounds almost like a pre-paid "retainer fee", like for lawyers.

Indeed it would be interesting to find out whether this is becoming a new trend , and whether it includes "everything". You made me curious, and so I am going to have do a Web search...

Seems like Certified Biller has made a good point.

[Steve Verno]

Sounds no different than the new Urgent Care Center at Orlando airport.  A sign I saw showed a visit for $125

Also, it looks like an informal contract with uninsured patients to me.  Not a ba idea.  You have no insurance, you get seen for $79.  Not too bad. Nice way to gain revenue and provide a needed service to someone with no insurance.. Bad thing, insurance companies wil want the same deal for their members.

On more thing:

Patient comes in and pays $79. Asks for statement of what would be charged if had insurance.   lets say fee is $150.  Sends claim for $150 and is reimbursed $150.  OR, patient is HMO patient, doesnt tell doctor and sends bill for reimbursement.  HMO files complaint with State that provider is violating FS 641.3154 (FL HMO Law).  State orders doctor to reimburse patient, places license on probation or revokes license and doctor is ordered to send claim  Claim is denied for timely filing, Doctor loses in the end.