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Am I required to see all insurances?

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  • Am I required to see all insurances?

    Upon initiation of my employment with my hospital it seems that I was enrolled in virtually all insurances. Some of the companies negotiated rates look as if they are from 1950. Am I entitled to refuse to accept these patients even though I may be contracted with the insurance through the hospital?

    ps: I’m an oral surgeon and am talking strictly elective, dental coded procedures (mainly third molars, sedations and simple extractions). Of course I’d see any emergency or medical issue (tmj, trauma, etc).

  • #2
    Speak to medical staff. And/or legal. There are 2 possible issues I can think of (possible more):

    1. The hospital expects you to see everyone as termed in your contract with them. You say no, they might push you out.

    2. The insurance most likely expects you to see their members, as you are contracted into the plan, unless whomever did your enrollment carved out (negotiated) an exclusion for you (highly doubt this).

    How I would pursue this:

    Speak with medical staff about you wanting to re-negotiate your rates. If the hospital credentialed you, they may have credentialed everyone else, & may be able to request higher rates for you. Especially if other doctors in the hospital are getting higher rates. And if other doctors are not, you should make them aware so it can be brought up at a medical staff meeting.

    If the hospital can't/won't assist, then you should be free to negotiate with the insurances yourself. If this happens, get in writing, what your expectations from the hospital are. If you are able to disconnect yourself from certain insurances without violating your hospital contract, then you can negotiate your rates & drop as you desire. If the hospital requires you to be on the insurances, then you have to decide if the overall picture is worth it, staying with the hospital or not.

    Right now / tomorrow, you should probably see the patients. Not doing so could put you in violation of your insurance contract, which could put you in violation of your hospital contract.
    $1 saved = >$1 earned. ✓


    • #3
      If you’re in network, then you’re on the hook for in-network fees, whether favorable or crappy.

      Consider the poor reimbursement for D7140s and D7210s as a loss leader for those sweet, sweet Le Forts and facial reconstructions. Alternatively, learn ICD codes as well as CDT codes, spend some time rigorously analyzing both insurance fee schedules and actual reimbursements after all claims, denials and appeals.

      Once you have a good handle on what procedures are fairly compensated and which are not, consider approaching your hospital about dropping the worst insurance plans.

      One other approach might be to bifurcate your practice. If your hospital is okay with this, see patients at the hospital for big reconstructive cases. Do third molar extractions and routine work exclusively at another location under another legal entity. This may be enough separation to let you elect not to treat wisdom tooth extractions and other non-life threatening non-hospital procedures at your private clinic if there’s a terrible insurance fee schedule. I’d recommend consulting with a health care attorney in your state and running everything by your hospital before making that leap.


      • #4
        OP your question is probably answered in your contract

        almost certainly you agreed to let your employer contract for you when you signed all the various papers they presented to you
        And it makes sense from your employers perspective. If they are going to employ you, they don’t want you out of network with a bunch of players.

        From your perspective, does it matter At the end of the day, with regards to the number on your paycheck?

        Crappy reimbursement is crappy reimbursement, and at the end of the day it should matter to everyone. But if you are in an employed model and it doesn’t affect your paycheck, it matters less.


        • #5
          How are you paid as an employee?


          • #6
            Argument #876 for self employment.


            • #7
              Thanks everyone for your input. Has been very helpful. I’ll avoid brash actions and continue to try to work this out as suggested.

              To loeffy and jacoavlu: pay structure is base salary or 50% net professional billing (whichever is higher, reconciled at end of fiscal year), so unfortunately at the moment I have to have a stake in collections. I’ve been working with the hospital to move to an RVU system. We have agreed on a fair rate for medical RVUs but we continue disagree over dental RVU rates. Dental RVUs aren’t really a thing so we are having to come up with a brand new system. There have been 2 issues thus far:

              1. They want to assign a dental RVU value based on without accounting for the fact that dental collections (as a percentage) is significantly higher than medical. The disagreement amounts to about $14 per RVU and at 7k plus RVUs per year it’s a big drop.

              2. I’ve continued to work with them and we seemed to have agreed on a hybrid (RVUs for medical and net professional billing for dental). Now of course they want to reconsider if Net professional billing should be 50% based on the percent allocation of resources toward use of medical vs dental billing. I can’t imagine that analysis will work in my favor. Nevertheless as I’ve researched line by line my last year and a half worth of production it’s become clear some of the privately insured patients collections are not what they should be. Industry standard is close to 90% collections but we are at 50% and below with some companies. Truthfully, I do not feel electively sedating a patient and taking out 4 impacted wisdom teeth is worth the associated risk if I’m only going to make $500 or less on the case (hence the original post).


              • #8
                Thanks for follow up. It sounds like you have a very good handle on things. if the crappy reimbursement and collection rates affects your pay you are wise to be invested in improving that

                Hank has a lot of expertise in this area. Maybe you could figure out a way to get those patients taken care of somewhere else.

                or you could go all in and offer to take over payer contract negotiation and billing and collection for your professional services.


                • #9
                  How much do you get paid if you bill sedation to medical rather than dental?


                  • #10
                    Originally posted by Hank View Post
                    How much do you get paid if you bill sedation to medical rather than dental?
                    To tell you the truth I didn’t know I’d be allowed to bill medical for sedation. I’ve always billed d9222 or d9239 and figured the cpt sedation codes would be limited to anesthesiologists. Now that you ask though I realize there must be a mechanism for other non anesthesiologists to bill for sedation. I’ll have to look into it and compare. It’s still a small piece of the pie though. A set of 4 full bony third molars and 30 minutes of moderate sedation runs close to 2800 and only 400 of that is the sedation.