Posts Tagged ‘physician reimbursement’

2013 Medicare Physician Fee Schedule Released

July 10, 2012 1 comment

CMS has released the Physician Fee Schedule for 2013 has been released. The fee schedule will be officially published July 20th and will become finalized November 1. Primary Care will sill see a 16% increase in reimbursement and specialities will see a 33% decrease in reimbursement.  Here exactly is how it is broken down by specialty.


Family Practice        7%
Internal Medicine    5%
Geriatricians              4%
Radiation Oncology     -15%
Radiology                       -4%
Anesthesiology            -3%
Cardiology                     -3%
Vascular Surgery        -3%
Pathology                     -2%
Urology                         -2%
Neurosurgery               -1%

No Effect
General Surgery
Plastic Surgery


Keywords: family medicine, family practice medicine, internal medicine, health care, medicare fee schedule, medicare, reimbursement, health plan, medical practice, U.S. Health and Human Services


Health Insurance Company Scheme Alert: Downcoding

June 28, 2012 Leave a comment

Physicians are finally beginning to drop insurance carriers due to the downcoding “scam” that insurers are using in order to greatly enhance their profits. Downcoding specifically is when an insurer unilaterally decides after services have been rendered to reduce the amount of reimbursements a physician (even hospital) can receive. According to the American Medical Association, most physicians believe this practice is a scam aimed directly at giving insurers as much profit as possible and this specific issue is what physicians complain to the AMA the most about.

CPT Codes Most Downcoded by Insurance Company:
Code:                                                    Medicare Rate:                                         Usual Downcoding Amount
99205 (new pt office visit)               $213.60
99204 (level 4 new office visit)       $170.47                                                      $43.13
99203 (leve 3 new office visit)         $110.92                                                       $59.55
99202 (level 2 new office visit)        $76.88                                                        $34.04
99201  (level 1 new office visit)        $44.77                                                         $32.11
99215  (level 5 established patient)  $149.60
99214  (level 4 established patient)  $111.39                                                      $38.21
99213  (level 3 established patient)   $74.46                                                      $36.93
99212  (level 2 established patient)   $44.77                                                      $29.69
99211 (level 1 established patient)     $22.39
9234 (outpatient observation)            $142.68
99233 (level 3 hospital progress note)   $108.67                                                $34.01
99232 (level 2 hospital progress note)   $75.78                                                  $32.89
99231 (level 1 hospital follow up)            $42.12                                                  $33.66

Average % difference between usual downcoding amount and normal Medicare rate is 49%.
( Source 2)
—————————————————————————————————————————————— Aetna

– Paid $6,270,000 settlement for downcoding dentist claims  (Source 3)
Blue Cross Blue Shield
– downcoded Anesthesiologist claims (Source 4)
-downcoded Urologist claims in Kansas (Source 4)
Physician exposes massive  “scam” run by Humana (Source 1)
– Humana underpaid by $108.47 on code 99215 when should have paid $149.60
-Humana underpaid by  $27.13 on code 99213 when should have paid $74.46




Keywords: medical coding, medical billing, health care insurance, health plan, united healthcare, humana, blue cross blue shield

Breaking News: Health Insurance Companies to Uphold Health Reform Provisions

June 14, 2012 Leave a comment

Breaking News…………………………………….

The for-profit health insurance companies of UnitedHealthcare, Aetna, and Humana have come out saying that they will uphold provisions in the Affordable Care Act regardless of how the U.S. Supreme Court rules later this month. Key provisions they especially will uphold include: keeping kids on parents insurance until age 26, covering preventive services,  maintaining independent process of claim denials, and no lifetime limits on coverage. The not-for-profit insurers are already planning to uphold provisions as well. The for-profit companies have decided to take this position only because they see the way this can greatly enhance profit for their shareholders and that they definitely do not want to miss out on anything that will  maximize profit.

Press Releases of the for-profits announcing their position on this matter can be read here:

51% of Primary Care Physicians Stop Accepting Medicaid Patients

June 13, 2012 Leave a comment

Primary care physicians are struggling to survive in today’s economic climate. They of all the medical specialties have the lowest reimbursement rates and it is causing great harm to their bottom line. The fact that insurance  companies have been deliberately holding back reimbursement from physicians as well as continue to defraud Medicare and Medicaid in order to protect company profits does not help the matter either (Source 1). On the flip side of things, this is having a severely negative impact on patient access. According to a recent study released by Jackson Healthcare, 51% of physicians plan to no longer accept new Medicaid patients. In addition, 26% of primary care physicians have stopped accepting new Medicare patients (Source 2). Health and Human Services estimates that 13 million – 26 million will be new Medicaid enrollees thanks to the Affordable Care Act by 2020 (Source 3).  The private sector, states, and the federal government (HHS) need to fix this situation now before it gets any worse. Otherwise, we will have a huge crisis on our hands and thus no primary care physicians to care for Medicaid patients.





U.S. Congress Working to Replace Physician Sustainable Growth Rate

May 17, 2012 Leave a comment

The U.S. Congress is currently working on legislation to replace the physician sustainable growth rate. Since 2002, this has become a highly debated topic in Congress that has resulted in 14 CRs (short-term measure) being passed that were aimed to delay a 30% cut to physician Medicare payments. H.R. 5707 introduced and aimed at replacing the SGR.

To get things started, The U.S. Senate Finance Committee held a roundtable discussion on the matter last week. You can view the discussion at In a statement, Chairman Max Baucus (D-MT) said : “Medicare’s sustainable growth rate (SGR) formula has not worked as planned. The annual cuts the formula calls for have snowballed the problem.” Ranking member Orrin Hatch (R-UT) said in a statement: “We must provide a stable foundation for paying physicians today, not five or 10 years from now.”

On May 9, a billed aimed at replacing the SGR was introduced. H.R. 5707: Medicare Physician Payment Innovation Act of 2012 was officially introduced in the House by members Allyson Schwartz (D-PA, former hospital CEO) and Dr. Joe Heck ,DO (R-NV, physician). The bill can be read here: In order for the bill to be successful, it will need to have FULL support by all of the physicians in Congress. The physicians that need to be encouraged to pass it are: John Barrasso (R-WY), Tom Coburn (R-OK), Rand Paul (R-KY), Dan Benishek (R-MI), John Boustany (R-LA), Paul Broun (R-GA), Michael Burgess (R-TX), Larry Buschon (R-IN), Bill Cassidy (R-LA), Scott DesJarlais (R-TN), John Fleming (R-LA), Phil Gingrey (R-GA), Paul Gosar (R-AZ), Andy Harris (R-MD), Nan Hayworth (R-NY), Ron Paul (R-TX), Tom Price (R-GA), Phil Roe (R-TN), Donna Christensen (D-VI), and Jim McDermott (D-WA).

Stay tuned to this blog for further updates on this story.



Physicians Say NO to Accountable Care Organizations

May 7, 2012 Leave a comment

Physicians in large numbers are rejecting Accountable Care Organizations (ACO). According to a survey by MedScape, physicians believe that these type of organizations are way to risky and are very vulnerable to being defrauded by insurance companies (evidence of insurance companies defrauding Medicare coming in next blog post). MedScape had 3,200 physicians respond to their survey and they came up with the following results:

5% of physicians want to be involved in an ACO

42% say physician alignment is impossible and is primary reason for not moving forward with ACO development

50% believe ACO federal guidelines will have a negative impact on patient care

52% say their income will be dramatically reduced

67% say they will not reduce the amounts of tests and procedures they order in order to comply with federal ACO guidelines

As you can see, there is a very large amount of physician resistance when it comes to ACOs.  In order for the ACOs and other alternative models to be successful, physicians MUST be in support of them. Otherwise, the concept will never work.


Health Insurance Companies to Give Rebates to Consumers

May 2, 2012 Leave a comment

Health insurance companies in USA will be giving over $1,000,000,000 in rebates back to the consumer this year for failing to meet the required 80/20 medical loss ratio rule. This is a rule established in the Affordable Care Act that requires insurers to actually pay 80% of premium dollars to a patient’s care and not let it be used for greedy shareholder and executive profits. Profits and revenue of insurers are down nearly 5% (according to CNBC) as a direct result of the 80/20 rule. The insurance lobby can try to repeal this part of the ACA but their efforts will be futile since Health and Human Services has already implemented and adopted it as one of their own rules. The 80/20 provision (now rule) was brilliantly written by the Congressional Healthcare Caucus, Congressional Physician Caucus, U.S. Senate Health Education Labor and Pensions Committee, U.S. Senate Finance Committee, and U.S. Senate Commerce Committee back when I was writing health care policy in Congress in 2008.

Source:  CNBC


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