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Wednesday, July 3, 2013
Clinic Owner: With Medicare and Medicaid, ‘Your Practice May Not Last Long’
By Jose Reque Martinez @ 10:06 PM :: 3621 Views :: Health Care, Small Business

by Jose Reque Martinez

A West Oahu medical clinic owner employs two MDs and accepts patients with Medicare and Medicaid.  He doesn’t want to go public due to fear of retaliation—which itself is telling—but here is what he told me, in an interview last week, about why some MDs are refusing Medicare and Medicaid patients:

"We see every patient no matter what type of insurance they have. Whether its Medicaid, Medicare, or private insurance.

"Some facilities and some physicians, feel that they're overwhelmed with certain types of insurance, especially Medicare HMOs.   (Medicare) sets their reimbursements very low and (the MDs) always get audited by those plans. Sometimes the audit of medical records can be between 30-50 charts or 50 patients, and for doctors that can be very stressing because it takes time from their own schedule and use their personal time to look for those charts and get ready for those audits.  Sometimes the audit can take a week, and because of those certain things they feel that they don't want to participate with Medicare--in addition to their low reimbursement.

"They have to have a balance of private plans in addition to Medicare and Medicaid.  For example if your population of patients is heavily inclined to Medicare and Medicaid then your reimbursements are low, and you depend too much on the government and that's not good.  You need more of the other side.  You need a higher percentage of PPO plans more than the government plans.

"All doctors care for their patients.  That's why they go to medical school, to take care of the sick.  But sometimes because of policies by the government, rules and regulations makes it difficult to do that.  So the doctors sometimes don't have a choice but to stop taking in Medicaid or Medicare patients. And sometimes they have patients that they schedule--but there are also a lot of cancellations that come with those patients.

"My advice would be to have a good balance of population.  Have a strong percentage of PPO plans because that's where the money, they pay a higher reimbursement compared with Medicare or Medicaid.  If you have a good percentage of PPO plans, for example 60% or even 70% PPO, you have a good balance.  The other percent can be Medicare or Medicaid.

"Physicians have a lot of expenses.  If you have a population or a type of insurance, in this case Medicare or Medicaid, that is (a greater percentage of your patients) than your PPO plans, you are at a risk that your practice may not last long compared to other practices that have a good balance of insurances.

"To much dependence on the government is not good. Because if you have a strong population of Medicare or Medicaid, the government can dictate.  For example if the government says next year that their taking a cut of 5% then you are going to suffer the 5% cut, because your population of patients are basically Medicare or Medicaid.  And what are you going to do as a physician?  Are you going to let people go to make up the loss?  Do you have to open another day, work more hours to make up the loss of the reimbursements?  That's the risk if you have a lot of Medicare or Medicaid.

"I think every physician should take a look internally: Where is their money coming from?  What percentage of the practice is dedicated to seeing PPO patients and what percentage is to seeing Medicare and Medicaid patients?  If you have a good balance, then your practice will continue to provide good care to the patients.”

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