Dr. Molly’s Weblog

Molly O’Shea starts a revolution in pediatric care

Insurance musings September 25, 2008

Filed under: Uncategorized — Dr Molly OShea @ 10:25 pm

Getting paid for what I do every day is harder than you would think.  I have run into a multitude of challenges when it comes to billing.  When I brought my brother Tom into the business, his job was to do my billing.  Now bear in mind he has absolutely no experience in this arena although he has worked in medical settings for much of his life and bear in mind that although I know how to code for what I do, completing the claims forms, doing the appeals and figuring out the reasons for the rejections is not something I have any experience with.  Soooooo, come to find out that even though I sent all of my stuff to United HealthCare this summer about my change in practice setting and tax id number and even though they put it all in their system correctly they never activated me as a provider so every single United claim has been rejected.  That is a hassle but isn’t so bad since United isn’t my largest insurer but it seems that we screwed up the claims for all of Blue Cross Blue Shield.  About fifty percent of my patients have Blue Cross sooooo let’s just say I was really happy when Tom figured out why the claims were rejected and was able to resubmit them today.  The issue of course is that we have huge numbers of claims for services provided six or seven weeks ago that have not been paid….this creates a cash flow nightmare and takes days and days of my employees’ time to figure out, correct and redo.

There are medical practices all over the country that have begun to see patients on a cash only basis, charging a flat monthly or yearly fee for all the medical care provided by the doctor during that time period.  It is like a health club of sorts.  You pay your dues and you can either go or not depending on your mood (which for me is about 40 times the first month, 20 the second, 3 the third and then never again).  I know that the need for medical care is less optional than going to the gym but the thought of never having to deal with insurers is really appealing.  These practices survive and thrive because they don’t need the numbers of staff that traditional offices do.  If a practice of 3 doctors could eliminate the two full time employees that deal with the insurance companies, and could charge a flat fee of $100 per month per patient (about 3-5 copays for most folks) and could each have 500 patients, they would make way more than enough to pay the other employees, the rent and supplies and still take home what they make now without the hassles of insurance.  I can really see the appeal.  Of course with a family of two parents and three kids, $500/month may be out of the realm of possibility for many families but if you only then had to have catastrophic (hospital) coverage the cost of insuring the family would be much lower.  An average family of 5 that has to buy their own insurance (either privately or through payroll deduction) pays a minimum of $800/month for coverage that still has significant copays.  If you could get catastrophic (hospital) coverage only for the same family for about $170/month then the additional cost of $500 monthly for everyone to have unlimited primary care office visits would be a savings.  Things like vaccines would have to be done at the Health Department and families would either need to pay cash for medications or pay extra for a prescription rider but this still seems like a good deal for healthy people.  Children and adults with significant chronic problems requiring frequent specialty care and prescriptions wouldn’t fare well in this model so it isn’t for everyone but it is an intriguing way to deliver care.

I am not about to change my practice model (at least not yet!) but I have to say after the last few months dealing with the insurance companies, I feel ready to throw in the towel!

Deal with rejection, revise your plan and keep flossing and each day will be your best!

Molly O’Shea, MD  Birmingham Pediatrics + Wellness Center



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