I appreciate the response, it sounds like we have some overlapping industry experiences where we've seen different things, which is interesting.
>>>>>>>>>> This is a common excuse given by industry. Its also BS.
Just to reiterate I'm not saying the reasons I gave are "good" reasons, it's more a statement of what's currently going on. I think the analogies are a little unfair but I agree with your overall point as it applies to elective procedures in certain settings. I think for emergent cases or complications the discussion gets more nuanced. The other point I'd make is that providers can't just decide to "simplify" the claim, the claim has to accurately reflect what occurred during the visit, so if things went sideways and other stuff was done then they need to document/bill for that because they are required to do so. There's also downstream reasons for this like reporting on quality/cost metrics and obviously if they bill for things that didn't occur that's fraud. Besides my anesthesia example, another clear example is an inpatient stay where you're billing an MS-DRG, you have to code in the severity of the case which is going to vary. And to reiterate, I think there are tons of clinicians that would love to move away from itemizing everything and doing something like surgerycenterok, but they are at the whim of the government (medicare/medicaid) and private insurance companies documentation requirements.
I'm aware of surgerycenterok, I'm a fan. Worth mentioning is they can't give pricing on anything done outside their purview (so imaging, labs, physical therapy, complications that send you elsewhere, etc). Definitely a step in the right direction. Side note there's quite a few places like this they just don't advertise it as openly.
>>>>>>>>>> This is true. They don't know because no one has bothered to translate a scheduled case into specific CPTs and/or looked up rates rates with insurer. So someone dropped the ball.
In my experience, payors are typically very uncooperative when making a request such as this. If you ask them any questions related to the contract/pricing they just tell you no.
>>>>>>>>>> Actually, you are misinformed here. The vast majority of contracts for independent providers are simple affairs that are % of medicare rates.
This is a tough one to swallow :) I'm going on ~5 years reading god knows how many of these contracts and writing software/doing analyses to enable practices to provide accurate pricing information. And if I didn't read the contract myself, I maintained/saw how it was implemented on the backend. This spanned small provider groups to the largest in the country, contracts from small payors to the largest in the country, and private/government contracts so I feel like my exposure is pretty well rounded to have a feel for things. But I could very well have a blindspot and we may also be talking about different things. Maybe you've mostly dealt with elective procedures at private practices where you mostly worry about professional fees? Or maybe you're alluding to the industry standard of comparing your contract to % of medicare to see if it's good or not? It's pretty common they'll say "oh we get paid 165% of medicare", but this is just in aggregate their contract may not even mention medicare.
This is interesting though because most contracts being % of medicare is the opposite of my experience. The vast majority have not been % of medicare (it may be a single component of their contract but there's much more to the terms). The handful of contracts that I saw that were truly just % of medicare were usually at smaller private practices in less competitive markets (eg some places in the Midwest). For what it's worth it's still not just % of medicare. There's an entire pricing methodology that underpins the "% of medicare" that is defined by medicare (eg depending on what else is on the claim there may be subsequent adjustments that trigger, then there's totally different rules/methods for different types of stays, etc). For example a really simple adjustment is a multiple procedure adjustment. Medicare publishes a list of procedures that qualify under this adjustment. If I get both my knees replaced and I bill for the procedure code twice I will not get paid the medicare rate times two. The second knee replacement will be adjusted 50% off. This is an extremely simple example but there's a whole slew of adjustments/nuance to the pricing methodologies, and then you add the fact that there's nothing preventing adjustments from stacking (unless the contract says they don't stack in certain situations). And I'm also just talking about the professional fee above.
All of the following were things I commonly encountered in contracts, all of which impacted the price estimates we generated: bill types like inpatient and outpatient were often very messy, handling different sites of service (clinic, asc, hospital, etc), various DRG standards, APCs, EAPGs, diagnosis codes, revenue codes, bundling agreements, modifiers, adjustments (multiple procedure, multiple radiology, multiple endoscopy, mid level provider, etc), carve outs, GPCI adjusted rates, different rules/schedules based on specialty, individual providers, location, 3rd party schedules, proprietary (meaning no one gets access / knows how it works) schedules and entire pricing methodologies that are a weird flavor of medicare pricing methodologies like 3M and optum, what quarter/year schedule is being referenced, what happens if a procedure isn't on the schedule do you grab the first time it appears in the future or the current year rates, is there a hierarchy of schedules to follow, fallback schedules, etc. To top it all off, frequently the contracts didn't outline many of the above nuances. They were assumptions made by the payor (not defined in the contract) that were only revealed until we asked them why our estimates were out of alignment.
This also doesn't even talk about the industry shift that is happening behind the scenes from fee for service to value based care. The value based care contracts I've seen only add an additional layer of complexity. How providers get reimbursed has been on a steep upward complexity curve since the 70s/80s (back when payment was based on Usual, Customary, and Reasonable charges). I would absolutely love to simplify things.
>>>>>>>>>> In my experience, some of the data fields are reliably accurate. For the rest, we are actually working on a solution. But let's not make perfect the enemy of the good.
Yeah, I would say it tended to be accurate, but when it was inaccurate and you then had a weird estimate and then an upset patient it was pretty frustrating for everyone involved. But I totally agree, that we shouldn't make perfect the enemy of the good. The other thing that was frustrating with the clearinghouses/payors was how frequently they'd have outages or the latency with someone's eligibility status if their plan changed.
>>>>>>>>>> This is a common excuse given by industry. Its also BS.
Just to reiterate I'm not saying the reasons I gave are "good" reasons, it's more a statement of what's currently going on. I think the analogies are a little unfair but I agree with your overall point as it applies to elective procedures in certain settings. I think for emergent cases or complications the discussion gets more nuanced. The other point I'd make is that providers can't just decide to "simplify" the claim, the claim has to accurately reflect what occurred during the visit, so if things went sideways and other stuff was done then they need to document/bill for that because they are required to do so. There's also downstream reasons for this like reporting on quality/cost metrics and obviously if they bill for things that didn't occur that's fraud. Besides my anesthesia example, another clear example is an inpatient stay where you're billing an MS-DRG, you have to code in the severity of the case which is going to vary. And to reiterate, I think there are tons of clinicians that would love to move away from itemizing everything and doing something like surgerycenterok, but they are at the whim of the government (medicare/medicaid) and private insurance companies documentation requirements.
I'm aware of surgerycenterok, I'm a fan. Worth mentioning is they can't give pricing on anything done outside their purview (so imaging, labs, physical therapy, complications that send you elsewhere, etc). Definitely a step in the right direction. Side note there's quite a few places like this they just don't advertise it as openly.
>>>>>>>>>> This is true. They don't know because no one has bothered to translate a scheduled case into specific CPTs and/or looked up rates rates with insurer. So someone dropped the ball.
In my experience, payors are typically very uncooperative when making a request such as this. If you ask them any questions related to the contract/pricing they just tell you no.
>>>>>>>>>> Actually, you are misinformed here. The vast majority of contracts for independent providers are simple affairs that are % of medicare rates.
This is a tough one to swallow :) I'm going on ~5 years reading god knows how many of these contracts and writing software/doing analyses to enable practices to provide accurate pricing information. And if I didn't read the contract myself, I maintained/saw how it was implemented on the backend. This spanned small provider groups to the largest in the country, contracts from small payors to the largest in the country, and private/government contracts so I feel like my exposure is pretty well rounded to have a feel for things. But I could very well have a blindspot and we may also be talking about different things. Maybe you've mostly dealt with elective procedures at private practices where you mostly worry about professional fees? Or maybe you're alluding to the industry standard of comparing your contract to % of medicare to see if it's good or not? It's pretty common they'll say "oh we get paid 165% of medicare", but this is just in aggregate their contract may not even mention medicare.
This is interesting though because most contracts being % of medicare is the opposite of my experience. The vast majority have not been % of medicare (it may be a single component of their contract but there's much more to the terms). The handful of contracts that I saw that were truly just % of medicare were usually at smaller private practices in less competitive markets (eg some places in the Midwest). For what it's worth it's still not just % of medicare. There's an entire pricing methodology that underpins the "% of medicare" that is defined by medicare (eg depending on what else is on the claim there may be subsequent adjustments that trigger, then there's totally different rules/methods for different types of stays, etc). For example a really simple adjustment is a multiple procedure adjustment. Medicare publishes a list of procedures that qualify under this adjustment. If I get both my knees replaced and I bill for the procedure code twice I will not get paid the medicare rate times two. The second knee replacement will be adjusted 50% off. This is an extremely simple example but there's a whole slew of adjustments/nuance to the pricing methodologies, and then you add the fact that there's nothing preventing adjustments from stacking (unless the contract says they don't stack in certain situations). And I'm also just talking about the professional fee above.
All of the following were things I commonly encountered in contracts, all of which impacted the price estimates we generated: bill types like inpatient and outpatient were often very messy, handling different sites of service (clinic, asc, hospital, etc), various DRG standards, APCs, EAPGs, diagnosis codes, revenue codes, bundling agreements, modifiers, adjustments (multiple procedure, multiple radiology, multiple endoscopy, mid level provider, etc), carve outs, GPCI adjusted rates, different rules/schedules based on specialty, individual providers, location, 3rd party schedules, proprietary (meaning no one gets access / knows how it works) schedules and entire pricing methodologies that are a weird flavor of medicare pricing methodologies like 3M and optum, what quarter/year schedule is being referenced, what happens if a procedure isn't on the schedule do you grab the first time it appears in the future or the current year rates, is there a hierarchy of schedules to follow, fallback schedules, etc. To top it all off, frequently the contracts didn't outline many of the above nuances. They were assumptions made by the payor (not defined in the contract) that were only revealed until we asked them why our estimates were out of alignment.
This also doesn't even talk about the industry shift that is happening behind the scenes from fee for service to value based care. The value based care contracts I've seen only add an additional layer of complexity. How providers get reimbursed has been on a steep upward complexity curve since the 70s/80s (back when payment was based on Usual, Customary, and Reasonable charges). I would absolutely love to simplify things.
>>>>>>>>>> In my experience, some of the data fields are reliably accurate. For the rest, we are actually working on a solution. But let's not make perfect the enemy of the good.
Yeah, I would say it tended to be accurate, but when it was inaccurate and you then had a weird estimate and then an upset patient it was pretty frustrating for everyone involved. But I totally agree, that we shouldn't make perfect the enemy of the good. The other thing that was frustrating with the clearinghouses/payors was how frequently they'd have outages or the latency with someone's eligibility status if their plan changed.