It Might Be 30% Less Than Medicare!

Why Our 23 Million Veterans Still May Not Be Getting The Healthcare They Deserve?

We have all read and heard the news that our military men and women who put their lives on the line every day to project our county and allow us freedom we so often take for granted. Our veterans come back from combat with complex medical issues and we all agree that they all deserve nothing but the very best healthcare care.

The Veterans Choice Program was started in 2014 to allow our veterans under certain conditions to be treated by civilian physicians outside of the Department of Veterans Affairs (VA) healthcare program for reasons such as; wait times of more than 30 days, or, distance to a VA hospital of more that 40 miles to see a primary care physician.

After all the hoopla in 2017 when the (VA) healthcare program was exposed for long wait times, appalling facility conditions and long drivetimes Veterans Choice Program which supposedly is being quoted as a “game changer” did not make the impact that is was supposed to. In August 2017, the President signed the VA Choice and Quality Employment Act of 2017 which authorized $2.1 billion in additional funds for the Veterans Choice Program. Where is all that tax payers money spent? It’s not coming to you.

Many private practice physicians contract with TrIcare to allow them to provide civilian health benefits for U.S Armed Forces military personnel, military retirees, and their dependents, including some members of the Reserve Component. Tricare is the civilian care component of the Military Health System. Tricare is often managed through a third-party payer that wins a bid to manage health care costs of our military personal, including but not limited to benefits, providers, ancillary, hospital and pharmaceutical networks as well as processing claims and payments at a reduced cost. For outpatient providers 30% less than the Medicare fee schedule to be exact. Can you really provide our veterans with quality care at such low costs? I don’t think so.

As a healthcare consultant working primarily in the outpatient space for over 30 years I have spent more hours than I would like to count reviewing and negotiating provider contracts. Not an easy task to say the least. Physicians went to school to treat patients, very little time is spent in medical school teaching business management and how to manage a private practice in a highly regulated, payment shrinking environment. The pulse of a practice is to make sure that it’s heart is healthy. A healthy heart is critical to the overall health and wellbeing of a practice. A healthy heart is predicated on providing cost effective healthcare to patients, managing costs, receiving accurate and timely reimbursement per the terms of your contract, which we all know can be a challenge.

Understanding your payer contracts and what and how you are being reimbursed is critical to being heart healthy.

Most physicians do not know where their payer contracts are, never mind what they say or what they have contractually committed to. Many have no idea what they are being reimbursed. Most providers do not know what the actual cost is of delivering healthcare to patients and accept payer contracts that reimburse less than their costs. We can agree that is not a sound business practice.

According to a new study published in the Journal of Investigative Dermatology American military personnel who served in the blazing deserts of Iraq and Afghanistan returned home with an increased risk of skin cancer.

I was recently asked by a client in Florida who specializes in the treatment of complex skin cancers to secure a contract to take care of our veterans (due to confidentiality and price fixing regulations, I am unable to name the payer, though they know who they are). A formal proposal was submitted articulating the education, experience, cost effective treatments provide. We submitted case studies showing the millions of dollars our client is saving all his contracted health plans with the conservative treatments he provides. Such as an 85-year old man who had been treated at a local wound center for non-healing wounds of his scalp. A local dermatologist treated the wounds with shave biopsies resulting in exposure of the skull. The patient was then referred to a Wound Center where the wounds desiccated. He was treated for 9 months, 27 visits, for debridement procedures and underwent a Human Skin Equivalent skin graft that failed. An estimate of charges reveals that at a minimum the dermatologist charges were $228.44, another plastic surgeon (who the patient saw before our client) charged $399.90. The Wound Center (using codes 99203, 99212, 15920-15946) could have easily charged over $100,000.00 of treatment for this patient. By the time the patient was seen by my client, the wounds consisted of an anterior scalp wound with bare dead bone and a posterior scalp wound with barely viable bone. The patient was treated with petrolatum and bandages and the posterior wound healed in 4 months after 13 visits. The charges totaled $657.12. (The anterior scalp wound, through progressing nicely with moist wound care, was closed when a new rapidly enlarging scalp skin cancer required surgery for cure. We submitted many other case studies showing our clients clinical value and letters of recommendation from many referring physicians that participate in the government health plan.

For this level of care our client was offered 70 yes 70% of the government health plans fee schedule. I was shocked to say the least. Never in my career has a physician been offered such an appalling reimbursement rate. With rent for space increasing annually, employees expecting annual pay increases, the cost of malpractice, medical and surgical supplies increasing; how does any health plan expect a provider to provide timely quality healthcare? Where is all the money going that is supposed to be spent on our veteran’s healthcare? Certainly not to the providers that actually provide the care. How many of you reading this article have accepted this reimbursement rate?

When I pushed back and requested a 100% of the Medicare fee schedule, I received an email indicating that the health plan was responsible for deliverable demands for the government program. Discount guarantees (this means rate increases beyond their fee schedule) is one of the major directives that the health plan manages for the government program. The contractual agreement rates I was requesting the health plan cannot approve. The health plan values and sincerely appreciates the commitment of its providers. Ultimately, we cannot give you something we cannot give other providers. This means other providers are accepting a 30% discount for treating our veterans.

My final push back was that “I clearly understand that the United States needs to provide to all its citizens affordable healthcare, which continues to rise at a rate more than any other industry in this country. Even though the providers who actually provide the care to the patients receive reimbursements decreases their expenses continue to rise. It’s very interesting. You nor I would continue to come to work if each year our employer decreases our salary, though we work long hours and meet all our employer’s goals. I know my staff for sure would not. I understand if you are unable to offer my client 100% of the Medicare fee schedule. If that is the case; what is a reasonable reimbursement rate you can offer my client?” I received no response.

It outrages me to think that 70% of the Medicare fee schedule is reasonable payment for a physician. My client cannot afford to provide quality patient care at this level of reimbursement and unfortunately declined to accept the contract. What a loss to our veterans who have served in the blistering sun in Iraq and Afghanistan often times without the application of sunscreen.

About The Author

President and CEO of United Physician Services

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