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Why Would Any Doctor Accept Medicaid?

A physician friend of mine posted a copy of her Medicaid reimbursement on Facebook. Take a look at the charges compared to the actual reimbursement. She is paid between $6.82 and $17.54 for an hour of her time (i.e. on average, she makes less than minimum wage when treating a patient on Medicaid).

The enthusiasm about expanding Medicaid coverage to the previously uninsured seems misplaced. Improved “access” to the healthcare system via Medicaid programs surely cannot result in lasting coverage. In-network physicians will continue to dwindle as their office overhead exceeds meager reimbursement levels.

In reality, treating Medicaid patients is charity work. The fact that any physicians accept Medicaid is a testament to their generosity of spirit and missionary mindset. Expanding their pro bono workloads is nothing to cheer about.  The Affordable Care Act’s “signature accomplishment” is tragically flawed – because offering health insurance to people that physicians cannot afford to accept is not better than being uninsured.

After all, improved access to nothing… offers nothing. Inviting physicians to work for less than minimum wage so that politicians can crow about millions of uninsured Americans now having access to healthcare, is ridiculous. Medicaid expansion is widening the gap between the haves and the have-nots. The saddest part is that the have-nots just don’t realize it yet.


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53 Responses to “Why Would Any Doctor Accept Medicaid?”

  1. WhiteCoat says:

    Since Medicaid is paying only 1.33% of many of these charges, the obvious answer is to charge $10,000 per office visit in order to cover office expenses.
    I wonder how patients would react if social security and disability benefits were cut by 98.666%.

  2. Steve O' says:

    The hallmark of a good scam is when the victim still thinks there’s an innocent mistake – that all this confusion can be cleared up. No, this is the real deal – this is the intent of the system, to stop payment to doctors. It’s not a misunderstanding – like that Genesis song about getting dumped. Sorry, he’s not noticing your nice smile anymore.

  3. Susan says:

    Since it’s charity work, why not let physicians write it off? They cannot at this time. I don’t think practices can survive. Several of my friends have been unable to collect from insurance agencies. I was told that the insurance company fails to pay the physician and then are bought buy another company so they don’t have to pay.People will leave the medical field if they cannot feed their families.

  4. Michael Smith says:

    None of those charges paid represent an hourly rate. Not one. 1 unit could be a dose of aspirin. That doesn’t take an hour to complete. Given that, the entire rest of your claims are highly questionable.

  5. Allison says:

    I’m the wife of a physician and it’s true that insurance companies don’t pay to the physicians and then get bought out and then the new company says that they don’t owe it because they bought it after the claims had been filed. Meanwhile, patients are still paying their monthly rates and their deductibles. Also, the reimbursement has gotten so low that it is not conducive to accept these patients but out of the goodness of my husbands heart he still does, increasing his time at work and maintaining all liability. Meanwhile, never getting paid. So he treats these patients basically free of charge and if anything were to go wrong they could turn around and sue him. Anyone that has anything negative to say about physician reimbursement (Michael Smith) should keep their mouths quiet until their smart enough to go through medical school themselves and see what it’s like.

  6. Dr. Val Jones says:

    Michael – I asked my friend what the “unit” represented and she said in most cases it was the equivalent of 1 hour of her time. Which claims are questionable?

    Allison – your husband has a good heart indeed. I appreciate all he does for the poor.

  7. Ruth says:

    Actually we do know..we’re a lot smarter than you think.

  8. Dave Mittman, PA says:

    I am a PA but have not practiced clinically in awhile. If this is accurate, the question is correct. Other than to give charity, why would anyone do this? Your legal, rent and other obligations are not covered, let alone a salary.
    Dave

  9. A Medicaid Accepting Doctor says:

    Which of those claims are questionable? Really? All of them are.

    What is shown in the picture is just a column of numbers under titles “charged” and “paid”. Anyone could make such a thing.

    How about showing specifically what service is being billed out? The payments may make more sense when you see what is actually being billed for.

    And Michael is almost certainly correct about the units comment, it isn’t even supposed to represent an hour of work for all services labelled 1 unit. That isn’t what 1 unit is supposed to mean.

    Even if you don’t believe me about one unit not being one hour, and you should, because what you are arguing here is totally absurd to anyone who actually understands how medicaid billing works, why does your friend bill out one hour of work at $94.38 for some things and $526.20 for others? And for what services to begin with? I’ve billed some outrageous hourly rates in my life, but billing a poor person $525 for an hour of physician service and expecting that to be paid in full seems outrageous even to me.

    Digging further, your friend has billed out about $4000 for 13 hours of work, roughly $300/hour in BILLING. Believe it or not, it’s actually pretty tough to make things work if you’re only billing $300/hour (unless you see only cash pay patients who actually pay you, and you get your collection rate up to over $200/hour).

    Lastly, you understand that it was your friend who signed an agreement indicating that she knew exactly how much she would be paid for her services in advance of the billing, right?

    Don’t get me wrong, Medicaid is a problem. It’s hard for a lot of docs to stay solvent seeing medicaid patients, and as has been pointed out here, many doctors actually lose money by seeing medicaid patients, and admirably do so out of kindness. Financially speaking, most doctors probably shouldn’t see medicaid patients. Access to care in many areas is horrible, as well as other problems. But disseminating misinformation under the title of a doctor isn’t going to help.

  10. JD says:

    The itemized list of “services” is probably not being shown because it would reverse the dramatic effect. From my limited experience with medical bills, the items are probably aspirin, box of Kleenex, etc…

    If you saw that list, your reaction would be more akin to, “How can a doctor ethically charge $500 for aspirin?”

    This list is a demonstration of how defective our medical system is at both extremes.

  11. Richard scott says:

    glad I’m too old. To evaluate charges need code and Medicaid billing suggests same.
    Years ago I was put on hospital financial committee and struggled understanding how hospital could say Medicaid was good when reimbursements were half of costs. The PhD economists tried to explain. I don’t think they had the chargeall which Brill mentions in “the bitter pill”.

  12. MK says:

    Hi All,

    I’m the friend who posted the Medicaid of NY EOB on a social network. Let me begin by saying, I’m glad the reimbursement numbers were so unbelievable, that several of the comments here questioned the veracity of this document!

    I’m an ophthalmologist who opened my own practice in August 2014. Each one of the units on the EOB represents either a comprehensive ophthalmic exam (92004 or 92014), a follow-up visit (92002 or 92012), or a specialized service such as a visual field examination. Each one of these services takes 30-60 minutes of my time and the time of my staff. As you may know, ophthalmic exams require dilation in most cases, which means the patient comes into the exam room at least twice, and may have other testing (for diabetic retinopathy, glaucoma, or corneal ectasias while they wait). I spend a considerable amount of time with my patients, and my diagnostic equipment does not come cheap. My overhead is $18,000 a month (or a little over $100/hour for an average of 22 workdays a month). The payments on the EOB represent services that take 30-60 minutes of my time, which works out to between $4.35 to $8.70/hr. In order to comply with HIPPA regulations, I did not supply the entire EOB (next column over to the right contained patient names), but trust me, this IS real.

    Thankfully, by virtue of its location, my practice does not draw large numbers of straight Medicaid patients, but I do consider accepting this insurance to be a “pro-bono” service to the community. If seeing Medicaid patients begins to interfere with bread and butter commercially insured patients, I will no doubt need to drop it. I was not aware Medicaid could be billed for a box of tissues or an aspirin, but I will definitely explore this possibility! Or more likely, if my practice ends up drawing larger numbers of Medicaid patients, I will almost certainly drop it. . .

  13. MK says:

    Oh, also about the comment that doctors signing onto an insurance knows “exactly” what they would be paid for their services — not true at all. Other than with Medicare, there is very little transparency in the fee schedules of insurances. I may provide a service that costs me $1600 in material costs alone (like Intacs implantation for keratoconus) and not find out until afterwards that the insurance (BCBS) will only pay out $330 dollars for it. They may grant me a prior authorization to do a procedure, but explicitly refuse to state how much they will reimburse me for it, until after the procedure is complete! Furthermore, the denials are absolutely astonishing, even after prior authorizations and referrals are provided. A managed Medicaid plan in NY (Metroplus) just denied payment for a corneal transplant I preformed on a patient, after it was already done. Obviously, I cannot refuse to see this patient. I now own his cornea! It would be considered abandonment, but they have decided that, even after my signing a contract with them and having been granted a prior-auth for the procedure, that I was an out of network doctor. Amazing! I’m taking them to small claims court, by the way.

  14. Kevin, MD says:

    The comments about a $100 aspirin are absurd. Doctors don’t bill for medications, at least I don’t and I don’t know anyone who does. We bill for services (time, exam, complexity of issues, amd medical decision making). I am always shocked by how many of my patients actually believe that I get a “%” of the bill for the xray or ct-scan I order. I get nothing regardless of how many medicines or tests I order. When I do procedures I am actually losing money and assuming risk, but I do it because I want to help my patients feel better. I could say no, but I took an oath. Believe it or not, few of us are laughing to the bank. The Governments solution to save money is to pay doctors less. Really? You want to pay is less, even though we already make less than at any point in history when adjusted for inflation. After I gave up my young adulthood to serve the people, and took on roughly 1/3 of a million dollars in debt? They pay less, well then we just will bill more. Its a silly game and its the patients that lose. It is the hospital that charges $100 for an aspirin, because they have to in order to survive. When someone with no insurance comes in at deaths door, do we turn them away? No, we treat them to two weeks in the ICU amd a week in step-dowm to the tune of $2 million. Who pays for that? We all do! Most of us are caring people. I would love to help as many as I can, but I need to be compensated for the sacrifices I have made in my life to be put in a position to help as many as I can. I made minimum wage as a resident physician when you worked out my hours and salary. When is my debt to society paid? I still owe more to Sallie Mae than my house is worth. Rich doctors are not the problem. Private insurance companies with record-breaking profits year after year are the problem.

  15. Academic Elite says:

    Cry me a river Kevin! Plenty of people make significant sacrifices in their lives for their career, country, and familiy. You did so to become a doctor. And I commend you for that. But why are your sacrifices more valuable? Because you’re in the medical field? You don’t see scientists and engineers complaining about their poverty level wages in grad school. At least not to the degree MDs complain about how their salaries aren’t high enough for their sacrifice. Your contributions to society aren’t any greater than any other professional. Frankly it can be argued that academics and entrepreneurs contribute in a much more significant and long lasting way. Be thankful you’re overpaid to the degree you are. Doctors being paid between 60-175k is reasonable. Any more than 175k is absurd.

  16. KJ says:

    Academic elite…not sure how you came up with your sense of fair valuation for physicians. Although I would agree many other professions are probably undervalued and underpaid. That said I know many engineers and “scientists” being an academic myself and they generally don’t work holidays, nights, or weekends (unless writing a paper or grant)nor deal with very sick patients or liability of doing so and they generally are paid as well or better then the average primary care doctor. Also medical school is considerably more expensive then the PhD programs as they generally do not have tuition coverage for teaching such as many PhD programs.

  17. MK says:

    Academic Elite, out of curiosity, how did you arrive at the number 175k, beyond which physician salaries are “Absurde”? And how many 36 hour shifts did you pull for how many days in a row in grad school? How many times did you fall asleep, while drive home after these shifts at red lights on your way home? How many people have helplessly watched die during your intern night shifts? How many times did you risk your life to place IVs in HIV positive or Hep C positive patients? How many times did you have to leave your friends or family sick in the hospital, to help strangers when your beeper went off? How many times did you have to comfort grieving parents, when you announced to them their child is forever handicapped, blinded, or dead, at 4:00 in the morning, while attending to trauma in the ER? Did you ever have to consider cryoprEserving your eggs, because you never had free time to date, as you watched everyone else around get married and have children? You can say what you want about other professions’ sacrifices, but NO ONE makes the sacrifices we make, emotional and physical. And no one invests financially like we do into out career. Why should an insurance CEO or a walk street financier make more than us? You seem to have everyone’s salary all fugues out. Do share how you’ve arrived at your lofty conclusions.

  18. Sara says:

    Dear Academic Elite. Please spend a shift with us. I get the impression that you’ve been fortunate with good health for you and yours. We wish you well. Our training can span reassurance, well-health visits, and minor procedures and screenings in the fortunate. However, nature can be cruel, and we stay up all night and sacrifice to TRANSPLANT ORGANS, RESTORE VISION, and save lives from HEART ATTACKS, and repair NEWBORNS. Not to mention diagnose and treat devastating diseases like lupus, diabetes, and medical “zebras.” Please spend a shift with us, and watch us hold our exhaustion, hold our splanchnic fear when repairing a non-beating heart while the patient is thermally cooled, hold our emotions when diagnosing an awful cancer, hold someone’s hand with an end-of-life discussion, hold our hunger, and hold our bladders. Please do not put a number on it. You would want us, but I hope you never need us. By your calculations, using a 70 hour workweek over 50 weeks, all that expertise is worth $50/hour. The UPS driver delivering prosthetic valves, parts, and precious metal containing pieces that make people feel normal, makes $80,000/year. Yes, we all do our job, but please “be an academic,” and get some experience and data before jumping to conclusions. Be well.

  19. Dr C says:

    I wonder how many envy doctors because we make too much money. This is what our president is trying to do, He wants to make us look like the bad insensible guys. How many of us can deal with nonsense policies and books of legalities that only benefits the attorneys who were overpaid to create them and who will sue you for not giving a piece a paper to patients, with so many regulations and nonsense technology that force us to increase our overhead dramatically and at the same time being paid less with no hope that our income could increase in the future. How many of you that criticize doctors can leave with the same salary year after year. What about bad doctors? Of course there are bad ones, those should be sued and should not be allowed to work anymore for being a disgrace to the profession. At the same time, boggus lawsuits should be paid by the attorney who promotes them.

  20. Steve O' says:

    And, Academic Elite, I’ve done both – a “real” Ph.D. in a hard science. Then I went into medicine because it was a personal calling. Since it was a calling, I cannot regret that I did; but absent that calling, I would have severe regrets.
    In First World countries, there is social and economic support of BOTH the hard sciences and medicine, because the civilization sees them as added value to the community at large. Unlike in America, one of the very last of the Second World countries, the valuation is not based upon income and salary – Michigan’s $5M per year football coach does not merit ranking as one of the elite of the university, based upon salary and stature, in other countries.
    A death-battle between PhD and MD is pitiful; America looks down on both.
    Streetwalkers are paid more than panhandlers – does that give them advanced social status in America? It likely does. In the great autocracies of the 20th century, most of which fell in the early 1990’s, our social underpinnings have crumbled. Acheivement is mocked, aggression and bullying is superficially scorned and universally practiced, and we have come up with a social structure that gives merit to the sociopaths. We are merely one of the last remnants of the anti-human collectivism that was Modernism; and although most of our fellow sovereign states are in the dust, we – and our fellow survivor North Korea – stumble onwards long after our expiry date.

  21. Academic Elite says:

    KJ: Not all doctors are permanently on call, or work nights. But every academic I know is working through their vacations and working long hours. Just because they aren’t on campus doesn’t mean they aren’t working on some aspect of their research or teaching. So I would say either your experiences are uncommon or we work in very different fields in academia.

    You have a fair point about the debt medical students incur. But frankly they new that going in. My entire family is in the medical industry. No one put a gun to their head to go into medicine. Medical doctors (MDs) need to stop complaining about putting themselves in debt to realize their dreams. I posit that small business owners and entrepreneurs take on far more financial risk than most or all medical professionals. Starting a company can cost hundreds of thousands if not millions of dollars. But you don’t here about successful entrepreneurs or business owners whining about how hard it is and how the system has to change for them. Also a number of these business owner are scraping by in their personal lives and at times making less than minimum wage before their company or small business takes off. MDs need to take personal responsibility for their decisions and stop expecting the rest of society to hold them up as some sort of pinnacle of humanity. You’re not saints. Your professionals being paid to perform a service. That’s why it’s called fee for service…

    MK:

    Your argument is nonsense. For one women in academia face the same exact struggle in terms of starting a family. The same is true for any working women seeking a fulfilling career. Small business owner and entrepreneurs take on much larger financial risks than what you have quoted. Academics work generally 70 hours on average and up to 90 when nearing deadlines (which is very often). Engineers work similar hours in industry. Both have fields which require late night work such as the medical imaging field (since things like MRIs and CT scanners are being used during the day for medical diagnosis). That sort of work can last until 7 in the morning. Engineers do work 36 hours shifts. But engineers just call that work…..

    Also to further enlighten you engineers and Scientists constantly put themselves in danger. Have you ever heard of the Manhattan project or CERN or Fermilab. Do you honestly think there is no risk with those experiments? For good measure consider school teachers. They can barely even be considered middle class. They work 60-70 hours a week and put their hearts into their work just as much or more so than any doctor. Or for that matter consider anyone in the military…Again just to clarify your argument is pure nonsense and emotion. But wait I’m not a doctor so I can’t comprehend…What total nonsense.

    Sara:

    I had a progressive form of cancer at the age of 18. But even at a young age I recognized I was alive because of research done in biochemistry. My oncologist even recognized this. I also suffer from other chronic and debilitating illnesses as well. I find it entirely pedantic and glib to argue that someone who doesn’t awe and admire your professional choices must be naive. I respect medical doctors and their role in society. That doesn’t mean they are worth more than $175,000 annually. Also as far I have read $175,000 is above the 95% of incomes in North America. Again academics and engineers actually work comparable hours and make far less money. But they don’t complain. Or at the very least they aren’t as vocal. You should all just be grateful you have had the opportunities you have had and the salaries you have. If you don’t like how your field is turning out then lead it and change it. But please stop complaining. Politically it makes no sense. You’re not winning any hearts or minds with that attitude.There are people living in abject poverty in our country that carry themselves better then a number of your peers.

  22. Academic Elite says:

    DR C’: Very passive aggressive. I can see you must have a wonderful bedside manner…If you’re asking me if I envy the money you MDs make the answer is no. I can make far more in my field by developing start ups. Higher risk but higher reward. But frankly I make enough money as is. I’m very happy with my choices and my career. But most people could care less about either of our careers and fields. Don’t kid yourself. To answer your other question about maintaining salaries, most can’t unless you are already wealthy and successful. No job has a COLA that truly adjusts for inflation let alone provides a real annual raise. At least not in this economy. But I guess you’ll just blame that on the president too.

    Steve O’: I agree somewhat with your general sentiment. Most Americans could care less about medicine, science, and engineering…That is until something goes wrong…Doctors are still overpaid though. I agree it’s hard to get your money. But you are all in the upper echelon of society. Just have some consistency. Support everyone who is overworked to have increased salaries or hourly rates. Yet I’ve never heard anyone in the medical field pushing for Tyson chicken workers to be paid reasonable wages and be given a sanitary and safe working environment.

  23. Kevin says:

    I would actually like to know what this doctor is charging $511.41 for. Or $526.20? Or $94.38? Those show up quite a bit. For full disclosure, it would be better to post the full bill rather than just their charges and their reimbursement. It’s interesting that they charged $526.20 twice and were reimbursed $17.54 for one and $7.02 for the other. Maybe this doctor has problems filling out the medical billing paperwork correctly. Showing this page with no context is virtually useless.

  24. Academic Elite says:

    I agree. “Articles” like this are really here to waste time.

  25. California Doctor says:

    This comment is towards Academic Elite.
    No argument will ever change your mind with your disdain for physicians. So I will not both responding to your comments or rebuttals. Just remember that many physicians are now closing their practices and many others are simply not accepting obamacare patients. So you can berate and put down physicians. Let’s just hope that the best and brightest continue to enter medicine. I mean why should they, given the public’s disdain for them. Hopefully you never need a physician. Since you have such a superior complex about yourself.

  26. brian says:

    To the folks moaning about the sacrifices doctors make. Get over yourself. My sister is a soldier and a police officer. She fought a fricking war. She could literally be shot and killed everyday. So cut the “no one makes the sacrifices we make” BS. Yes you should be on the higherend of the compensation scale. Sure. But no your sacrifices are in no way unique or even that extreme.

  27. Academic Elite says:

    Hi California Doctor:

    I’ve got nothing but love for doctors. My entire family is in medicine. I respect all of them. But I have no respect for whiners. Unfortunately there are far to many whiners in the medical field. I haven’t heard a single cogent argument as to why doctors “deserve” more money. It generally seems to devolve into an emotional argument. Again I don’t hear doctors advocating equal pay for women or increasing the minimum wages or supporting work unions. Why should anyone care about your wealth when their is no observable reciprocity? I’m honestly asking.

  28. Academic Elite says:

    I totally agree with you Brian! If anyone should be paid more it is soldiers and teachers. Both completely undervalued.

  29. Megan says:

    I am surprised no one has mentioned the malpractice insurance costs associated with medicine. That alone takes a nice chunk away from doctors. And since so many people don’t seem to care about the sacrifices doctors make (in life, health, school and money) then let’s encourage all physicians to stop seeing Medicaid patients. Surely that will stop the “whining” people keep mentioning above. And while we are at it lets have all doctor offices force patients to sign arbitration contracts so that malpractice insurance doesn’t keep climbing while reimbursements decline.

  30. Academic Elite says:

    Hi Megan. I think the problem isn’t as black and white as you’d like to portray it. There are doctors who commit malpractice all over this country. I have no qualms that the system is flawed. But why not opt for a systems that isn’t fee for service. Canada and European countries have it figured out. You also make 70% more than your foreign counterparts. Also why not support higher taxes to pay entirely for undergraduate and professional schooling? You would loose your elitism but at least you wouldn’t have the looming debt. In terms of mal practice insurance…well you guys should learn to police yourselves better.

    If you’re arguing that we should change healthcare in America then I am on board with the basic premise. Doctors should be paid for overall health outcomes. Fee for service is part of the problem. It allows for things like oncologists to commit fraud and diagnose healthy patients with cancer to boost their salaries. This happened in America! Unbelievable. Also you’re in a naturally higher risk profession. If you don’t like that then work in a Hospital that will subsidize your insurance. Or stop practicing.

  31. Megan says:

    Over simplifying, huh? You keep comparing the sacrifices doctors make to that of start ups and researchers but you don’t include the fact that the reward to those achievements can far out weigh what doctors can accomplish – especially monetarily. And yet they don’t have the same scrutiny or constant threat of lawsuits that doctors often face. So you value a doctor at $175,000? Let’s take 40% for the government, 5% for student loans, another 5% in disability insurance and whoa, that whining doctor is making about $100k. Those greedy jerks! By the way – I am not a doctor and I was raised by a personal injury attorney. My view isn’t skewed – it’s a moderate look at the real problem of declining reimbursement rates.

  32. California Doctor says:

    This is directed at Academic Elite. Just wondering about background. You claim to come from a family who has many members in the medical profession. Yet you are not a physician. Could your anger towards physicians and their compensation stem from you not getting into medical school and feeling inferior with your family? Of course you will probably disagree and say otherwise. But where is all is anger and envy towards physicians coming from. My best guess is you felt inferior with your family. And that is why you don’t think physicians deserve anything but modest compensation. You have never been in our shoes. I find it peculiar that you have the most outspoken comments aimed at physicians. I do feel sorry for you. It must have been rough living in a family of overachieving physicians and you not meeting their expectations. Maybe this helps explain your hate towards physicians. It’s just sad. Very sad !!

  33. Dr C says:

    Nobody questions that other professions should earn more money. The discussion here was about physicians and the low payment from the government. You can find really bad teachers and really bad veterans and of course extremely bad doctors. Why should we support the unions when they charge you a lot of money for nothing? Inequality? I think it is all propaganda for elections. But who am I? I might be passive aggressive but as Doctors we care for our patients regardless of what brain washed people like Academic Elite might think.

  34. MBMD says:

    I’m a doc. I can see it from all sides and have really enjoyed this back and forth. Thanks to all. I’m more upset with spending over a billion to elect our politicians every cycle… Talk about people who should be “paid for performance”! Freedom isn’t cheap either but over a Trillion on two wars during the last decade? Just think how many teachers, academics, and medical services that would have bought. And don’t even get me started with lobbyists. Talk about leaches on our system of government… If you wanna change academia, healthcare, education, and all the other endless problems we face it all starts by getting money out of politics. Until we do that, we’re just wasting our time.

  35. John Fembup says:

    Why is it such a difficult thing simply to post the service codes corresponding to the billing lines?

  36. Can't work with medicaid. says:

    That explanation of benefits does not appear to be accurate. I have yet to be reimbursed at such a low rate in primary care.
    However, I quit accepting Medicaid because it costs me around 90 dollars including all expenses to see a patient if I see 32 patients a day and Medicaid pays an average of 60 dollars per visit. So my choice was to see a patient every 7 minutes which is about 2 minutes of face to face time… or go broke.
    Increasing fees does nothing, we get paid a fee determined by the payor, not negotiable, take it or leave it. This does not include the high denial rate of about 30 percent of claims for no reason.
    Unlike our good ophthalmologist I can’t afford to take pro Bono cases.
    I understand this posting is about the flaws of medicaid reimbursement so there you go.

    I have to ask Mr. Academic, if you or your colleagues work fast pace, non stop for 8 hours a day, Monday to Saturday, then do paperwork for 1 or 2 hours a day on average, attend hospital and insurance meetings twice a month, get called at night twice a week and get sued an average of 2 times during their career?
    I suspect you are looking at the life of plastic surgeons or maybe Dr. Oz but not real life physicians like myself.
    Academics like you usually think they have everything figured out but they are out of touch with reality.
    Do you make less than 175K a year sir?

  37. Nat says:

    interedting article. I delivered a baby this year, my delivery cost of the family over $12,000 with PPO insurance coverage. Simple delivery was close to $25-$30,000. Positions will make money. They don’t do probono. The doctor spent with this patient may be two or five minutes. So, doctors will still make money to maintain their practices and above average salaries. They should for the hard work they are doing!

  38. RJG says:

    this has been going on for decades and is getting worse. As a primary care doc, I never netted anywhere near what the procedure guys made. Take a long hard look at how much the insurance and government bureaucrats are skimming off the health care dollar. I gave up trying to keep up with this and retired.

  39. Josh says:

    I am shocked by Michael Smith’s analysis that “one unit can be a dose of aspirin.” Doctors don’t bill for medications, or even give medications, pharmacies do. It shows the severe lack of understanding many people have about RVUs and how physicians get paid. We do NOT get paid by ordering expensive tests or medications.

  40. Charles says:

    Mr Academic Elite (interesting username by the way),
    Ideally a capitalist economy determines how much a person earns based on their contribution to society, their level of skill, and the sacrifices they make to get there. Delivering healthcare is critical for society to function. Doctors spend 11-15 years of their life through rigorous training, and a board certified physician is very highly skilled. Finally, we make so many sacrifices (our youth spent in libraries and classrooms, our time spent away from spouses and away from watching our children grow up, our money with a quarter million in loans as we start our careers).

    And for what??? To have individuals like you misinform people that we are “overpaid” when if you consider all things it is the opposite? We are not what’s wrong with the healthcare system, the insurance executives acting as middlemen are.

    Very few doctors are rich or millionaires.

  41. Academic Elite says:

    Megan: Are you seriously trying to argue that $100,000 after taxes isn’t a great salary? My family came from nothing and we are thankful and grateful for our station in life. I’m curious how much you think other professions should be paid? In terms of sacrifice look at what the special forces endure. You don’t here them complaining about their salaries or their risk or what they gave up….

    Medicaid pays poorly I get it. I think everyone who knows someone in medicine knows this. I also agree that the medical system is broken and should be altered to provide a stable income to medical professionals. Medical professionals aren’t villains. They are generally respectable individuals that do good work. I respect and have admiration for medical doctors myself. Especially oncologists, internal medicine and surgeons. But they are not volunteering. They are professionals being paid.

    The whole reason I posted a comment was that an individual made a claim that doctors sacrifice the most and should be rewarded more. That frankly is unfounded. The right people don’t go into medicine for money.

  42. Academic Elite says:

    Charles: How do you define wealth? I think it’s a bit unrealistic to think that medical doctors aren’t at least generally in the upper middle class or high echelon. I’ve known medical doctors (surgeons, radiologists, family medicine) personally my whole life and I’ve never seen one in anything less than upper middle class housing.

    There is no denying you guys make sacrifices to get to your current station. But who doesn’t do so in order to succeed? What makes you special. Also 11-15 years? Are you including college? Last time I checked what differentiates you from others is med school (4), residency (3-5), fellowship (1-2). How are you arriving at 11-15?

    Also I don’t recall saying doctors are overpaid. What I did say was that they are paid enough. Hence stop complaining.

  43. Academic Elite says:

    Can’t work with Medicaid:

    Every professions has it’s down side. Yes academics work long hours. So do engineers and researchers in government labs and industry comparable to the hours you work. I am not aware of academics being sued but prior to tenure a career in academia is tenuous to say the least. Also the job market is far more crowded and it is unregulated in academia. It makes for great competition but tremendous stress.

    Again I know plenty of doctors in radiology, family medicine, internal medicine and various surgery specialties. They are all doing extremely well.

    Also I can understand your predicament with medicare. That’s outrageous.

  44. Academic Elite says:

    MBMD:

    LOL. I appreciate your comments. Couldn’t agree more. This country has been hurting every since Citizens United…DoD spending is outrageous.

  45. Academic Elite says:

    Hi Dr C:

    Not really sure what your point is. But you’re definitely making mine. I’m fine with medical professionals making hand over fist. As long as you fix the healthcare system and stop complaining about your “financial problems.” But when you complain in public you’re going to get a negative reaction. Especially when you community stands idle as the healthcare system is made ill by corporate interests, insurance companies and the poor machinations of politicians and bureaucrats.

  46. Academic Elite says:

    HI Cali Doctor:

    I’m actually quite open to what you have to say. I have no disdain for doctors. I hope you do well in your career and personal life. I have no ill will towards anyone. Perhaps I am missing something. Please let me know what your opinion is on the previously discussed matters.

  47. Academic Elite says:

    Megan: Also I would imagine that the largest reward in medicine isn’t monetary. If it is for an individual then I believe they are in the wrong line of business.

  48. Dr Keith says:

    Interesting dialogue. Emotional on both sides. As a physician, I agree most of us live relatively well in terms of reimbursement for a significant time sacrifice to get to the point of practice–changing slowly. I think the absurdity of comparing different paths to professions is impossible to follow or clearly discuss on a forum such as this. My viewpoint is that the discussion of Medicare/Medicaid reimbursement is the government model that insurance companies hope to “slide down to pay.” Meaning that private pay insurance would love nothing less than to negotiate down closer to government reimbursement. Thankfully that doesn’t occur or every physician practice would close. I make a comfortable living–not rich, comfortable. I could have done so as an engineer (and my retirement savings would be 9 years further along) or in academics as a PhD (left that program to go to medical school–would have had so much less debt). But I did choose to go to medical school. Not debating much of the above back and forth emotions and opinions. I do have a few comments about where this is headed. With larger numbers of government pay patients, practices will shut down or combine/sell out to reduce overhead, good and bad. Physicians will continue to spend more hours to meet their overhead (now with IT, support and new data entry personnel for an EHR that won’t talk to a large percentage of other EHRs in the country–what good was that mandate?). Where is it headed? Who in their right mind wants to go into medical school if this system continues? Other countries make the system work better someone said, but they don’t charge for medical school. In state tuition/living expenses in my state (poorer south) run $300K for medical school. Then 3-7 years for residency and/or fellowships before your first job. Now tack on practice overhead, malpractice that doesn’t decrease every year, 10 years to pay the student loans (hope you got through undergrad loan free), increasing fees to practice every year, cost of living increases for employees, uncertainty over future reimbursement, informed patients who come in and demand you explain why they can’t be on that medicine they saw advertised on TV (almost unique to the USA), or they read all about their problem on the Internet and now have all the facts–please explains to me why what I read wasn’t true, oh and don’t miss that diagnosis or you’ll be in court. Yeah, that is something for future doctors to look forward to in the next decade when they finally finish. Most of us could have done nearly anything we wanted in college. Often the brightest minds are drawn into medicine (academia as well). But the headaches, the challenges, the costs, will they be worth it? Not unless something changes. It is a calling for most, but logical thinking can overcome that if the rewards are so diminished.

    And as for the different billing structures on the units above? You bill certain units for first in depth visits, others for follow up, others for procedures, etc.

    An interesting aside pertinent: A plastic surgeon I know (who is not a cosmetic–they get cash for most of their work) starts his day on average at 7:30, used to work until about 2pm before all overhead was covered–he had many government pay patients. Now with the new EHR and its costs, he starts making money around 3:30-4:00. And again, a surgeon in private practice who does a lot of pro bono on weekends, and government pay patients most others won’t see. That is why I worry about our system being not sustainable for the quality of care we have…and whoy I worry about who will be my doctor in 25-30 years…and it is not all about money, but if it wasn’t for the money, the risk reward wouldn’t be worth it.

  49. Dr Keith says:

    By the way, I love my job. I made my decision and it has been a good one. I love dealing with my patients and their challenges. But at some point, you get tired and often jaded. Your patients rarely do what you tell them. Some patients will die. Others will leave because their insurance changed. Others treat you like you are a moron and act entitled. Others get angry.
    But most of them are still grateful, still respectful. For these we wake up each day and go to work. Stay up late reading journal articles. Sometimes look at a blog like this in the process and feel frustrated because medicine has and is changing and we want others to understand that change is good–and could be bad. We want more physicians involved in decisions, not people that have no clinical knowledge or training. But we aren’t heard, and the politicians keep moving forward with their pockets lines (yes, I have donated to politics, only a fool doesn’t know that without doing so you can’t be heard). We need changes that are not being addressed.

  50. A Medicaid Accepting Doctor says:

    @MK, okay, so you’ve posted a partial invoice that is real. I believe you that it’s really part of an invoice. I too am a real doctor who works with a lot of medicaid patients.

    I don’t believe that each of those codes “should” represent an hour of YOUR time. And you certainly should know that “units” of service are not hours of physician work. So can’t we drop the “hourly rate” argument at this point? It’s misleading, and appears to be intentionally misleading.

    You indicate that these services were for codes 92002, 92004, 92012, and 92014. None of these are big services. None of them. And if you don’t know that, you should. In terms of work RVU they range from 0.88 to 1.92. None of them are going to get you $500 from medicaid or medicare– never did before, and it’s not going to happen any time soon. For any non-doctor trying to decipher this and put it in relative terms, these codes are generally felt to require roughly 1/4 to 1/2 the amount of work that a doctor would do in doing a simple procedure like a tonsillectomy. These codes are on-par with a normal patient seeing a doctor for the first time for an uncomplicated problem– like seeing an internist for chronic heartburn, or returning to see your internist to switch a BP medication. So maybe we can also stop the hand waving about corneal transplants– these codes are not for the performance of corneal transplants, they are for eye exams.

    Again, for any non-doctors out there, if you want to test this out for yourself: schedule an appt with an ophthalmologist, see the doctor and time how long the doctor is actually in the room with you, and then look at your bill and see what was PAID, not billed, and what the billing code was. Report back if the doctor spends an hour in the room with you, bills a 92002, and gets PAID $500.

    You can get a good idea what you can expect payment wise for these codes by using resources such as these:
    http://www.cms.gov/apps/physician-fee-schedule/search/search-results.aspx?Y=0&T=0&HT=0&CT=3&H1=92014&M=5
    http://kff.org/medicaid/state-indicator/medicaid-to-medicare-fee-index/

    There are much more accurate and professional ways to estimate your payments in advance, the links above are just examples of publicly available resources that should allow you to make reasonable estimates of how much you can expect to get paid for various services under medicare and medicaid.

    There are problems in the system and there are things that don’t work, and there are payors who refuse to follow the rules, but that’s a different issue from what was argued in this post from the beginning. You actually SHOULD know roughly what you are supposed to get for your services in advance. If you don’t know this, how can you actually expect to argue in court that you’re not getting what you should?

    You’re obviously trying to make a practice work, and that’s very hard to do. Your overhead is about 1/3rd what mine is, so great job there! You may want to consider that your charges are a bit high, unless you’re seeing people who actually pay those rates with some regularity.

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