RE: REIMBURSEMENT MICROCLIMATES

[Guest guest]

,On reimbursement - nothing unusual about my codes.  I am submitting what most other folks are on this list - more 99214s than 13s and rare 212s, 10% or less 99215s and then the CPX codes of course.  ICD9s are the standard ya know 401.1 for HTN, 272.0 high chol etc...etc..Nothing fishy. no strange codes or magic spells.I happen to be in what I call " a high reimbursement microclimate"I think there are extremely great and extremely horrible "microclimates" for malpractice as well. I do not know how or why or who decides these things.  Some guy in an office somewhere plays with #s I guess....I am getting 85-100% of the billed fee by insurers generally. People say if I am getting 100% of my billed fee from insurers I should charge more.  I think it would be highway robbery if  I charged more as I already get 134-167 on my 99214s.  Don't ask me why.  I do not know ...???  Does anyone??PamelaPamela Wible, MDFamily & Community Medicine, LLC3575 st. #220 Eugene, OR 97405roxywible@...www.idealmedicalpractice.orgOn Mar 22, 2006, at 8:51 AM, Brock DO wrote: Yes I too have had the same question as to how you can average $112 per visit when most docs are averaging around $50/visit & of us those using EMR’s are about $75-$80/visit.  It still makes me wonder if you are inadvertently submitting visits under a specialist code, hospital place of service, something to cause a drastically higher reimbursement.  I recall the example of another doc on the list that was getting reimbursed something like $30+ for “venipuncture” vs the normal $3.  It was then discovered that she was submitting those as “therapeutic phlebotomy” codes rather than standard venipuncture (oops).  I just keep hearing the old adage in my head: if it sounds too good to be true, then it usually is.  Oh well, I can’t spend too much mental energy wondering about other doc’s practices but it still makes me say:  hmmm how can that be?     Re: what do doctors actually do Your last line struck me as so true.  Let's not consider ourselves more important than we actually are.  I have been in the business for 15 plus years  and have probably truly saved in way of lives 30-50. Maybe more, it is a hard thing to measure.  Would these people be there if I had not, maybe not, maybe so.  What we do in primary care is hard to put a value on in many ways.  How many amputations or heart attacks have I prevented?  How many caused?  How many have I prevented from going on dialysis?  How many strokes prevented?  I have no way of knowing.  If we take credit for every success , we must stare every failure in the face and also acknowledge that.  I believe it is better to be very humble in our dealings with patients. Brent > >>>> >> > >>>> >> i've been reading about the social burden of being a doctor and > >>>> > how it relates to low overhead practice with great interest. > >>>> >> > >>>> >>   there are some underlying fundamental precepts i like to keep > >>>> in > >>>> > mind when discussing these things. > >>>> >> > >>>> >>   they are: > >>>> >> > >>>> >>   health care is not a right or privilege; it is a basic human > >>>> > need, just like food, clothing and shelter.  everybody needs it. > >>>> >> > >>>> >>   good health care arises from a healthy doctor-patient > >>>> > relationship.  the relationship facilitates healthy choices > >>>> > resulting in good outcomes. > >>>> >> > >>>> >>   any framework surrounding the doctor-patient relationship must > >>>> > be defined by the needs of the doctor-patient relationship.  form > >>>> > follows function. > >>>> >> > >>>> >>   just my thoughts. > >>>> >> > >>>> >>   LL > >>>> >> > >>>> >> > >>>> >> --------------------------------- > >>>> >> Yahoo! Travel > >>>> >>  Find  great deals to the top 10 hottest destinations! > >>>> >> > >>>> > > >>>> > > >>>> > > >>>> > > >>>> > > >>>> > > >>>> > > >>>> >

[Guest guest]

,On reimbursement - nothing unusual about my codes.  I am submitting what most other folks are on this list - more 99214s than 13s and rare 212s, 10% or less 99215s and then the CPX codes of course.  ICD9s are the standard ya know 401.1 for HTN, 272.0 high chol etc...etc..Nothing fishy. no strange codes or magic spells.I happen to be in what I call " a high reimbursement microclimate"I think there are extremely great and extremely horrible "microclimates" for malpractice as well. I do not know how or why or who decides these things.  Some guy in an office somewhere plays with #s I guess....I am getting 85-100% of the billed fee by insurers generally. People say if I am getting 100% of my billed fee from insurers I should charge more.  I think it would be highway robbery if  I charged more as I already get 134-167 on my 99214s.  Don't ask me why.  I do not know ...???  Does anyone??PamelaPamela Wible, MDFamily & Community Medicine, LLC3575 st. #220 Eugene, OR 97405roxywible@...www.idealmedicalpractice.orgOn Mar 22, 2006, at 8:51 AM, Brock DO wrote: Yes I too have had the same question as to how you can average $112 per visit when most docs are averaging around $50/visit & of us those using EMR’s are about $75-$80/visit.  It still makes me wonder if you are inadvertently submitting visits under a specialist code, hospital place of service, something to cause a drastically higher reimbursement.  I recall the example of another doc on the list that was getting reimbursed something like $30+ for “venipuncture” vs the normal $3.  It was then discovered that she was submitting those as “therapeutic phlebotomy” codes rather than standard venipuncture (oops).  I just keep hearing the old adage in my head: if it sounds too good to be true, then it usually is.  Oh well, I can’t spend too much mental energy wondering about other doc’s practices but it still makes me say:  hmmm how can that be?     Re: what do doctors actually do Your last line struck me as so true.  Let's not consider ourselves more important than we actually are.  I have been in the business for 15 plus years  and have probably truly saved in way of lives 30-50. Maybe more, it is a hard thing to measure.  Would these people be there if I had not, maybe not, maybe so.  What we do in primary care is hard to put a value on in many ways.  How many amputations or heart attacks have I prevented?  How many caused?  How many have I prevented from going on dialysis?  How many strokes prevented?  I have no way of knowing.  If we take credit for every success , we must stare every failure in the face and also acknowledge that.  I believe it is better to be very humble in our dealings with patients. Brent > >>>> >> > >>>> >> i've been reading about the social burden of being a doctor and > >>>> > how it relates to low overhead practice with great interest. > >>>> >> > >>>> >>   there are some underlying fundamental precepts i like to keep > >>>> in > >>>> > mind when discussing these things. > >>>> >> > >>>> >>   they are: > >>>> >> > >>>> >>   health care is not a right or privilege; it is a basic human > >>>> > need, just like food, clothing and shelter.  everybody needs it. > >>>> >> > >>>> >>   good health care arises from a healthy doctor-patient > >>>> > relationship.  the relationship facilitates healthy choices > >>>> > resulting in good outcomes. > >>>> >> > >>>> >>   any framework surrounding the doctor-patient relationship must > >>>> > be defined by the needs of the doctor-patient relationship.  form > >>>> > follows function. > >>>> >> > >>>> >>   just my thoughts. > >>>> >> > >>>> >>   LL > >>>> >> > >>>> >> > >>>> >> --------------------------------- > >>>> >> Yahoo! Travel > >>>> >>  Find  great deals to the top 10 hottest destinations! > >>>> >> > >>>> > > >>>> > > >>>> > > >>>> > > >>>> > > >>>> > > >>>> > > >>>> >

[Guest guest]

That’s great for you if it is true,

but why are you the only one I’ve ever heard say this?  Even other

doctors from your area do not seem to confirm this extraordinary reimbursement,

but maybe they are trying to be more secretive about it.  Does your ex-partner

you mentioned work nearby?  If so, why is he unable to duplicate those rates? 

Also, I’ve looked at a few job postings for family docs in your neck of

the woods & they do not mention the greatly different reimbursement, and the

high starting salaries seem pretty typical (even a bit below average if

anything)..  I just find it hard to fathom that the upper mgt at those local

insurances do not realize that they could pay you 50% less & easily get

away with it, especially since that is what all of their competitors are doing

all across the country.  Hard to believe, but great for you though if accurate.

Re: what do

doctors actually do

Your last line struck me as so true. Let's

not consider ourselves

more important than we actually are.

I have been in the business for 15 plus

years and have probably

truly saved in way of lives 30-50. Maybe more, it

is a hard thing to

measure. Would these people be there if I

had not, maybe not, maybe

so.

What we do in primary care is hard to put a value

on in many ways.

How many amputations or heart attacks have I

prevented? How many

caused? How many have I prevented from going

on dialysis? How many

strokes prevented? I have no way of

knowing.

If we take credit for every success , we must

stare every failure in

the face and also acknowledge that. I

believe it is better to be

very humble in our dealings with patients.

Brent

> >>>> >>

> >>>> >> i've been reading

about the social burden of being a

doctor and

> >>>> > how it relates to low

overhead practice with great interest.

> >>>> >>

> >>>> >>Â Â there are

some underlying fundamental precepts i like

to keep

> >>>> in

> >>>> > mind when discussing

these things.

> >>>> >>

> >>>> >>Â Â they are:

> >>>> >>

> >>>> >>Â Â health

care is not a right or privilege; it is a basic

human

> >>>> > need, just like food,

clothing and shelter. everybody

needs it.

> >>>> >>

> >>>> >>Â Â good

health care arises from a healthy doctor-patient

> >>>> > relationship.Â

the relationship facilitates healthy choices

> >>>> > resulting in good

outcomes.

> >>>> >>

> >>>> >>Â Â any

framework surrounding the doctor-patient

relationship must

> >>>> > be defined by the needs

of the doctor-patient

relationship. form

> >>>> > follows function.

> >>>> >>

> >>>> >>Â Â just my

thoughts.

> >>>> >>

> >>>> >>Â Â LL

> >>>> >>

> >>>> >>

> >>>> >>

---------------------------------

> >>>> >> Yahoo! Travel

> >>>> >>Â FindÂ

great deals to the top 10 hottest destinations!

> >>>> >>

> >>>> >

> >>>> >

> >>>> >

> >>>> >

> >>>> >

> >>>> >

> >>>> >

> >>>> >

[Guest guest]

That’s great for you if it is true,

but why are you the only one I’ve ever heard say this?  Even other

doctors from your area do not seem to confirm this extraordinary reimbursement,

but maybe they are trying to be more secretive about it.  Does your ex-partner

you mentioned work nearby?  If so, why is he unable to duplicate those rates? 

Also, I’ve looked at a few job postings for family docs in your neck of

the woods & they do not mention the greatly different reimbursement, and the

high starting salaries seem pretty typical (even a bit below average if

anything)..  I just find it hard to fathom that the upper mgt at those local

insurances do not realize that they could pay you 50% less & easily get

away with it, especially since that is what all of their competitors are doing

all across the country.  Hard to believe, but great for you though if accurate.

Re: what do

doctors actually do

Your last line struck me as so true. Let's

not consider ourselves

more important than we actually are.

I have been in the business for 15 plus

years and have probably

truly saved in way of lives 30-50. Maybe more, it

is a hard thing to

measure. Would these people be there if I

had not, maybe not, maybe

so.

What we do in primary care is hard to put a value

on in many ways.

How many amputations or heart attacks have I

prevented? How many

caused? How many have I prevented from going

on dialysis? How many

strokes prevented? I have no way of

knowing.

If we take credit for every success , we must

stare every failure in

the face and also acknowledge that. I

believe it is better to be

very humble in our dealings with patients.

Brent

> >>>> >>

> >>>> >> i've been reading

about the social burden of being a

doctor and

> >>>> > how it relates to low

overhead practice with great interest.

> >>>> >>

> >>>> >>Â Â there are

some underlying fundamental precepts i like

to keep

> >>>> in

> >>>> > mind when discussing

these things.

> >>>> >>

> >>>> >>Â Â they are:

> >>>> >>

> >>>> >>Â Â health

care is not a right or privilege; it is a basic

human

> >>>> > need, just like food,

clothing and shelter. everybody

needs it.

> >>>> >>

> >>>> >>Â Â good

health care arises from a healthy doctor-patient

> >>>> > relationship.Â

the relationship facilitates healthy choices

> >>>> > resulting in good

outcomes.

> >>>> >>

> >>>> >>Â Â any

framework surrounding the doctor-patient

relationship must

> >>>> > be defined by the needs

of the doctor-patient

relationship. form

> >>>> > follows function.

> >>>> >>

> >>>> >>Â Â just my

thoughts.

> >>>> >>

> >>>> >>Â Â LL

> >>>> >>

> >>>> >>

> >>>> >>

---------------------------------

> >>>> >> Yahoo! Travel

> >>>> >>Â FindÂ

great deals to the top 10 hottest destinations!

> >>>> >>

> >>>> >

> >>>> >

> >>>> >

> >>>> >

> >>>> >

> >>>> >

> >>>> >

> >>>> >

[Guest guest]

Believe me, the large groups which dominate my county (one large 100 doc group and another with 80 docs) rake it in I'm sure.  It just doesn't trickle down to the docs who are employees unless they are productivity hounds. Their starting salaries are comparatively low to other regions such as the SE USA for example.I think many docs in solo practice or small groups have been here for decades and I am not sure they communicate about this with others in Ohio or elsewhere.  I think it is a luxury that I even have time to contemplate any of this as most of my colleagues are "wheel to the grindstone" or whatever the phrase is.  I mean isn't it illegal to compare rates anyway??The other doc (my prior employer) is in Washington state - Olympia and I think he says they charge 109 for their 99214 and never come close to getting full payment from insurers often.He is a volume guy and gets his 360K on really high volume with tons of ancillaries. Another partner in the group can barely get over 90K and works his butt off seeing 21-22 pts/day. Overhead there requires one to get to 18/per day.So, why me?  I do not know.  Maybe I have a guardian angel? Maybe I am floating on the coattails of the large groups that must work hand and hand with the large insurers regionally and secretly (somehow) increase the rates. I really have no idea. I am BTW an open book sort of person and I share details openly and freely. I do not know if others are secretive, unaware of the discrepancies, or just so busy (most employed docs) and they do not even know what they are billing!!!!  Most docs who are employees seem so hands off on the business of medicine they really get their info from reading the newspaper.  They read about the malpractice crisis, yet have NO IDEA what they pay (via their large group) for malpractice.  They read about uninsured poor people, but have no idea what they are billing in their own offices for a 99213 or 99214!!I get the feeling most people (and docs) are so busy that there is little time for reflection on these issues and comparing rates across regions, insurers, states.  We do not generally have extra time on our hands like the executives who apparently do and set the rules we live by...Again, I feel it is a luxury that I can even sit back and contemplate politics, the business of medicine and transforming health care in this country.Pamela That’s great for you if it is true, but why are you the only one I’ve ever heard say this?  Even other doctors from your area do not seem to confirm this extraordinary reimbursement, but maybe they are trying to be more secretive about it.  Does your ex-partner you mentioned work nearby?  If so, why is he unable to duplicate those rates?  Also, I’ve looked at a few job postings for family docs in your neck of the woods & they do not mention the greatly different reimbursement, and the high starting salaries seem pretty typical (even a bit below average if anything)..  I just find it hard to fathom that the upper mgt at those local insurances do not realize that they could pay you 50% less & easily get away with it, especially since that is what all of their competitors are doing all across the country.  Hard to believe, but great for you though if accurate.   Re: what do doctors actually do Your last line struck me as so true.  Let's not consider ourselves more important than we actually are.  I have been in the business for 15 plus years  and have probably truly saved in way of lives 30-50. Maybe more, it is a hard thing to measure.  Would these people be there if I had not, maybe not, maybe so.  What we do in primary care is hard to put a value on in many ways.  How many amputations or heart attacks have I prevented?  How many caused?  How many have I prevented from going on dialysis?  How many strokes prevented?  I have no way of knowing.  If we take credit for every success , we must stare every failure in the face and also acknowledge that.  I believe it is better to be very humble in our dealings with patients. Brent > >>>> >> > >>>> >> i've been reading about the social burden of being a doctor and > >>>> > how it relates to low overhead practice with great interest. > >>>> >> > >>>> >>   there are some underlying fundamental precepts i like to keep > >>>> in > >>>> > mind when discussing these things. > >>>> >> > >>>> >>   they are: > >>>> >> > >>>> >>   health care is not a right or privilege; it is a basic human > >>>> > need, just like food, clothing and shelter.  everybody needs it. > >>>> >> > >>>> >>   good health care arises from a healthy doctor-patient > >>>> > relationship.  the relationship facilitates healthy choices > >>>> > resulting in good outcomes. > >>>> >> > >>>> >>   any framework surrounding the doctor-patient relationship must > >>>> > be defined by the needs of the doctor-patient relationship.  form > >>>> > follows function. > >>>> >> > >>>> >>   just my thoughts. > >>>> >> > >>>> >>   LL > >>>> >> > >>>> >> > >>>> >> --------------------------------- > >>>> >> Yahoo! Travel > >>>> >>  Find  great deals to the top 10 hottest destinations! > >>>> >> > >>>> > > >>>> > > >>>> > > >>>> > > >>>> > > >>>> > > >>>> > > >>>> >

[Guest guest]

Believe me, the large groups which dominate my county (one large 100 doc group and another with 80 docs) rake it in I'm sure.  It just doesn't trickle down to the docs who are employees unless they are productivity hounds. Their starting salaries are comparatively low to other regions such as the SE USA for example.I think many docs in solo practice or small groups have been here for decades and I am not sure they communicate about this with others in Ohio or elsewhere.  I think it is a luxury that I even have time to contemplate any of this as most of my colleagues are "wheel to the grindstone" or whatever the phrase is.  I mean isn't it illegal to compare rates anyway??The other doc (my prior employer) is in Washington state - Olympia and I think he says they charge 109 for their 99214 and never come close to getting full payment from insurers often.He is a volume guy and gets his 360K on really high volume with tons of ancillaries. Another partner in the group can barely get over 90K and works his butt off seeing 21-22 pts/day. Overhead there requires one to get to 18/per day.So, why me?  I do not know.  Maybe I have a guardian angel? Maybe I am floating on the coattails of the large groups that must work hand and hand with the large insurers regionally and secretly (somehow) increase the rates. I really have no idea. I am BTW an open book sort of person and I share details openly and freely. I do not know if others are secretive, unaware of the discrepancies, or just so busy (most employed docs) and they do not even know what they are billing!!!!  Most docs who are employees seem so hands off on the business of medicine they really get their info from reading the newspaper.  They read about the malpractice crisis, yet have NO IDEA what they pay (via their large group) for malpractice.  They read about uninsured poor people, but have no idea what they are billing in their own offices for a 99213 or 99214!!I get the feeling most people (and docs) are so busy that there is little time for reflection on these issues and comparing rates across regions, insurers, states.  We do not generally have extra time on our hands like the executives who apparently do and set the rules we live by...Again, I feel it is a luxury that I can even sit back and contemplate politics, the business of medicine and transforming health care in this country.Pamela That’s great for you if it is true, but why are you the only one I’ve ever heard say this?  Even other doctors from your area do not seem to confirm this extraordinary reimbursement, but maybe they are trying to be more secretive about it.  Does your ex-partner you mentioned work nearby?  If so, why is he unable to duplicate those rates?  Also, I’ve looked at a few job postings for family docs in your neck of the woods & they do not mention the greatly different reimbursement, and the high starting salaries seem pretty typical (even a bit below average if anything)..  I just find it hard to fathom that the upper mgt at those local insurances do not realize that they could pay you 50% less & easily get away with it, especially since that is what all of their competitors are doing all across the country.  Hard to believe, but great for you though if accurate.   Re: what do doctors actually do Your last line struck me as so true.  Let's not consider ourselves more important than we actually are.  I have been in the business for 15 plus years  and have probably truly saved in way of lives 30-50. Maybe more, it is a hard thing to measure.  Would these people be there if I had not, maybe not, maybe so.  What we do in primary care is hard to put a value on in many ways.  How many amputations or heart attacks have I prevented?  How many caused?  How many have I prevented from going on dialysis?  How many strokes prevented?  I have no way of knowing.  If we take credit for every success , we must stare every failure in the face and also acknowledge that.  I believe it is better to be very humble in our dealings with patients. Brent > >>>> >> > >>>> >> i've been reading about the social burden of being a doctor and > >>>> > how it relates to low overhead practice with great interest. > >>>> >> > >>>> >>   there are some underlying fundamental precepts i like to keep > >>>> in > >>>> > mind when discussing these things. > >>>> >> > >>>> >>   they are: > >>>> >> > >>>> >>   health care is not a right or privilege; it is a basic human > >>>> > need, just like food, clothing and shelter.  everybody needs it. > >>>> >> > >>>> >>   good health care arises from a healthy doctor-patient > >>>> > relationship.  the relationship facilitates healthy choices > >>>> > resulting in good outcomes. > >>>> >> > >>>> >>   any framework surrounding the doctor-patient relationship must > >>>> > be defined by the needs of the doctor-patient relationship.  form > >>>> > follows function. > >>>> >> > >>>> >>   just my thoughts. > >>>> >> > >>>> >>   LL > >>>> >> > >>>> >> > >>>> >> --------------------------------- > >>>> >> Yahoo! Travel > >>>> >>  Find  great deals to the top 10 hottest destinations! > >>>> >> > >>>> > > >>>> > > >>>> > > >>>> > > >>>> > > >>>> > > >>>> > > >>>> >

[Guest guest]

RE how we can bill for a "reasonable amount" so overhead = lower volume.

Much of this, as you point out, depends on your situation.

I like full disclosure, and technology that I can depend on, as well as good office support that helps me get the job done.

I've been in solo practice for the last 14 months, yet worked for a solo doc in a group of 3 for 2 years, a staff model HMO, and a hospital owned practice for the last 8 before going out on my own (when the hospital reorganized me out of my office, and "encouraged" the other FPs in the hospital system under contract to leave completely... another story).

1) Hospital or HMO employed docs are NOT shown EOBs-- at least in my experience-- even if you ASK! Just shown "how much you're loosing," trust US to manage you well. NOT!!!

2) Ancillaries can make up the difference, but you really need to watch what you're doing-- some don't pay as much as others, and you really need to be able to justify what you're doing, and why. EKGs really don't pay alot, but they're worth it to be sure that you can do a preop, check an arrhythmia, but also after awhile, you should be able to pay for the equipment.

3) Average visits-- varies depends on area of country. Mine, in western PA, also averages about $75/visit, including well care and rest of visits. Beware that 99215's do NOT depend on number of problems addressed, but criticalness of illness. Wish it weren't so, but it is. Initially, you may find that you're doing more well care (with E & M, and hope you're getting paid for both, thankfully my local BCBS does pay for both!), but over time, you may find that this doesn't hold up. Perhaps that's why you're so high?

Dr Matt Levin

Pittsburgh, PA

Re: REIMBURSEMENT "MICROCLIMATES"

Believe me, the large groups which dominate my county (one large 100 doc group and another with 80 docs) rake it in I'm sure. It just doesn't trickle down to the docs who are employees unless they are productivity hounds. Their starting salaries are comparatively low to other regions such as the SE USA for example.

I think many docs in solo practice or small groups have been here for decades and I am not sure they communicate about this with others in Ohio or elsewhere. I think it is a luxury that I even have time to contemplate any of this as most of my colleagues are "wheel to the grindstone" or whatever the phrase is. I mean isn't it illegal to compare rates anyway??

The other doc (my prior employer) is in Washington state - Olympia and I think he says they charge 109 for their 99214 and never come close to getting full payment from insurers often.He is a volume guy and gets his 360K on really high volume with tons of ancillaries. Another partner in the group can barely get over 90K and works his butt off seeing 21-22 pts/day. Overhead there requires one to get to 18/per day.

So, why me? I do not know. Maybe I have a guardian angel? Maybe I am floating on the coattails of the large groups that must work hand and hand with the large insurers regionally and secretly (somehow) increase the rates. I really have no idea. I am BTW an open book sort of person and I share details openly and freely.

I do not know if others are secretive, unaware of the discrepancies, or just so busy (most employed docs) and they do not even know what they are billing!!!! Most docs who are employees seem so hands off on the business of medicine they really get their info from reading the newspaper. They read about the malpractice crisis, yet have NO IDEA what they pay (via their large group) for malpractice. They read about uninsured poor people, but have no idea what they are billing in their own offices for a 99213 or 99214!!

I get the feeling most people (and docs) are so busy that there is little time for reflection on these issues and comparing rates across regions, insurers, states. We do not generally have extra time on our hands like the executives who apparently do and set the rules we live by...

Again, I feel it is a luxury that I can even sit back and contemplate politics, the business of medicine and transforming health care in this country.

Pamela

That’s great for you if it is true, but why are you the only one I’ve ever heard say this? Even other doctors from your area do not seem to confirm this extraordinary reimbursement, but maybe they are trying to be more secretive about it. Does your ex-partner you mentioned work nearby? If so, why is he unable to duplicate those rates? Also, I’ve looked at a few job postings for family docs in your neck of the woods & they do not mention the greatly different reimbursement, and the high starting salaries seem pretty typical (even a bit below average if anything).. I just find it hard to fathom that the upper mgt at those local insurances do not realize that they could pay you 50% less & easily get away with it, especially since that is what all of their competitors are doing all across the country. Hard to believe, but great for you though if accurate.

-----Original Message-----From: [mailto: ] On Behalf Of pamela wibleSent: Wednesday, March 22, 2006 12:42 PMTo: Subject: Re: REIMBURSEMENT "MICROCLIMATES"

,

On reimbursement - nothing unusual about my codes. I am submitting what most other folks are on this list - more 99214s than 13s and rare 212s, 10% or less 99215s and then the CPX codes of course. ICD9s are the standard ya know 401.1 for HTN, 272.0 high chol etc...etc..

Nothing fishy. no strange codes or magic spells.

I happen to be in what I call " a high reimbursement microclimate"

I think there are extremely great and extremely horrible "microclimates" for malpractice as well. I do not know how or why or who decides these things. Some guy in an office somewhere plays with #s I guess....

I am getting 85-100% of the billed fee by insurers generally. People say if I am getting 100% of my billed fee from insurers I should charge more. I think it would be highway robbery if I charged more as I already get 134-167 on my 99214s.

Don't ask me why. I do not know ...??? Does anyone??

Pamela

Pamela Wible, MD

Family & Community Medicine, LLC

3575 st. #220

Eugene, OR 97405

roxywible@...

www.idealmedicalpractice.org

Yes I too have had the same question as to how you can average $112 per visit when most docs are averaging around $50/visit & of us those using EMR’s are about $75-$80/visit. It still makes me wonder if you are inadvertently submitting visits under a specialist code, hospital place of service, something to cause a drastically higher reimbursement. I recall the example of another doc on the list that was getting reimbursed something like $30+ for “venipuncture” vs the normal $3. It was then discovered that she was submitting those as “therapeutic phlebotomy” codes rather than standard venipuncture (oops). I just keep hearing the old adage in my head: if it sounds too good to be true, then it usually is. Oh well, I can’t spend too much mental energy wondering about other doc’s practices but it still makes me say: hmmm how can that be?

-----Original Message-----From: [mailto: ] On Behalf Of pamela wibleSent: Wednesday, March 22, 2006 11:19 AMTo: Subject: Re: Re: what do doctors actually do

Yes! Agree! It is SPIRITUAL our work.

Analogy: Can you imagine a priest inserting the following folks between himself and his suffering client:

nurse

secretary

insurance agent

pharmacy rep

EMR techie

CPA

Attorney

and then helping the client and managing the crowd above concurrently???

We are healers. It is spiritual work. It is an honor.

Our profession is degraded when money is the bottom line, speed/productivity is rewarded and countless people are shoved between ourselves and our patient.

I spoke to my prior employer last night who I have a lot of respect for (even though he would have kept my bonus had I not pursued it). He was intrigued by my financial #s regarding my current LOVE (Low Overhead Volume) model and his HOVE (high overhead volume) model.

He wanted to clarify that I really bring in $112 or so per pt on average without "ancillaries" and I believe my "ancillaries" that I end up charging for (by time - more 99214s) are in the realm of spirituality, not an unnecessary set of labs or EKG (these thing were overordered at that clinic for $$$).

Testing has its place. Most folks come for healing and that is beyond the physical realm most of the time.

Regarding $$$$ and the bottom line, my prior employer (near partner had I stayed) said that I would be making around 360K (like him) had I stayed with them as my #s were close to his on productivity. He did understand why the LOVE model appealed to me though. I told him not all docs can see thrive in his model and he concurred. It takes a certain personailty, charisma, skill to see high numbers of patients well and remain balanced as a human being. We certainly are not providing for their spiritual needs in 10 minute visits with ancillary staff running in and out of the room and EKG machines beeping away in a frenzied atmosphere. I just do not see it happening.

Our work is at its foundation - spiritual.

Pamela

Pamela Wible, MD

Family & Community Medicine, LLC

3575 st. #220

Eugene, OR 97405

roxywible@...

www.idealmedicalpractice.org

At the risk of coming across as too heavy-duty, here are my thoughts on this topic:Our connection with each other--patients, family, colleagues, etc.--is beyond what is physical. We serve a source that is unaffected by what happens to our bodies, our lives. There is a level of energy, for lack of a better word, that we sort of float over during the business of our lives. If we can teach ourselves to quiet down our minds and allow that energy to rise, we can feel that source. It is limitless, joyful and does not change based on what is happening to us.It is precisely the sense of disconnection to this source why our spiritual brothers and sisters seek our services in our clinics. I believe that a slowed-down practice is more likely able to minister to their spiritual wounds. But only if we our relatively healed ourselves. This is, I believe, a part of our quest--to help elevate each other, or, more accurately, lower each other to feel that connection and influence a slight change. The change is an enhancement of our conscious selves to feel our deeper selves. Self-awareness. Prayer, meditation, art, work, whatever we lose ourselves in and feel joy through.Our role as physicians is just that: a role.We are infinitely more. Our other task is to discover that and celebrate it. And to influence others to feel it, too.I had a dream when I was 17 years old where I was told this exact message. There were 30 other people in the same room. Any of you out there?Occasionally, rarely, I sense with my patients that we were lead to each other so that this process can happen. When this takes place, my role as physician, acupuncturist, etc. suddenly feels unimportant. And the connection I share with them gives me the reassurance that I am in the right place at the right time. I trust that I am doing my best, and then I want to go to sleep. Feels good.CharlieNew Mountain Medicinelin, NCDate: Tue Mar 21 21:37:47 CST 2006To: Subject: Re: what do doctors actually doYour last line struck me as so true. Let's not consider ourselves more important than we actually are. I have been in the business for 15 plus years and have probably truly saved in way of lives 30-50. Maybe more, it is a hard thing to measure. Would these people be there if I had not, maybe not, maybe so. What we do in primary care is hard to put a value on in many ways. How many amputations or heart attacks have I prevented? How many caused? How many have I prevented from going on dialysis? How many strokes prevented? I have no way of knowing. If we take credit for every success , we must stare every failure in the face and also acknowledge that. I believe it is better to be very humble in our dealings with patients.Brent > >>>> >>> >>>> >> i've been reading about the social burden of being a doctor and> >>>> > how it relates to low overhead practice with great interest.> >>>> >>> >>>> >>  there are some underlying fundamental precepts i like to keep > >>>> in> >>>> > mind when discussing these things.> >>>> >>> >>>> >>  they are:> >>>> >>> >>>> >>  health care is not a right or privilege; it is a basic human> >>>> > need, just like food, clothing and shelter. everybody needs it.> >>>> >>> >>>> >>  good health care arises from a healthy doctor-patient> >>>> > relationship. the relationship facilitates healthy choices> >>>> > resulting in good outcomes.> >>>> >>> >>>> >>  any framework surrounding the doctor-patient relationship must> >>>> > be defined by the needs of the doctor-patient relationship. form> >>>> > follows function.> >>>> >>> >>>> >>  just my thoughts.> >>>> >>> >>>> >>  LL> >>>> >>> >>>> >>> >>>> >> ---------------------------------> >>>> >> Yahoo! Travel> >>>> >> Find great deals to the top 10 hottest destinations!> >>>> >>> >>>> >> >>>> >> >>>> >> >>>> >> >>>> >> >>>> >> >>>> >> >>>> >

[Guest guest]

RE how we can bill for a "reasonable amount" so overhead = lower volume.

Much of this, as you point out, depends on your situation.

I like full disclosure, and technology that I can depend on, as well as good office support that helps me get the job done.

I've been in solo practice for the last 14 months, yet worked for a solo doc in a group of 3 for 2 years, a staff model HMO, and a hospital owned practice for the last 8 before going out on my own (when the hospital reorganized me out of my office, and "encouraged" the other FPs in the hospital system under contract to leave completely... another story).

1) Hospital or HMO employed docs are NOT shown EOBs-- at least in my experience-- even if you ASK! Just shown "how much you're loosing," trust US to manage you well. NOT!!!

2) Ancillaries can make up the difference, but you really need to watch what you're doing-- some don't pay as much as others, and you really need to be able to justify what you're doing, and why. EKGs really don't pay alot, but they're worth it to be sure that you can do a preop, check an arrhythmia, but also after awhile, you should be able to pay for the equipment.

3) Average visits-- varies depends on area of country. Mine, in western PA, also averages about $75/visit, including well care and rest of visits. Beware that 99215's do NOT depend on number of problems addressed, but criticalness of illness. Wish it weren't so, but it is. Initially, you may find that you're doing more well care (with E & M, and hope you're getting paid for both, thankfully my local BCBS does pay for both!), but over time, you may find that this doesn't hold up. Perhaps that's why you're so high?

Dr Matt Levin

Pittsburgh, PA

Re: REIMBURSEMENT "MICROCLIMATES"

Believe me, the large groups which dominate my county (one large 100 doc group and another with 80 docs) rake it in I'm sure. It just doesn't trickle down to the docs who are employees unless they are productivity hounds. Their starting salaries are comparatively low to other regions such as the SE USA for example.

I think many docs in solo practice or small groups have been here for decades and I am not sure they communicate about this with others in Ohio or elsewhere. I think it is a luxury that I even have time to contemplate any of this as most of my colleagues are "wheel to the grindstone" or whatever the phrase is. I mean isn't it illegal to compare rates anyway??

The other doc (my prior employer) is in Washington state - Olympia and I think he says they charge 109 for their 99214 and never come close to getting full payment from insurers often.He is a volume guy and gets his 360K on really high volume with tons of ancillaries. Another partner in the group can barely get over 90K and works his butt off seeing 21-22 pts/day. Overhead there requires one to get to 18/per day.

So, why me? I do not know. Maybe I have a guardian angel? Maybe I am floating on the coattails of the large groups that must work hand and hand with the large insurers regionally and secretly (somehow) increase the rates. I really have no idea. I am BTW an open book sort of person and I share details openly and freely.

I do not know if others are secretive, unaware of the discrepancies, or just so busy (most employed docs) and they do not even know what they are billing!!!! Most docs who are employees seem so hands off on the business of medicine they really get their info from reading the newspaper. They read about the malpractice crisis, yet have NO IDEA what they pay (via their large group) for malpractice. They read about uninsured poor people, but have no idea what they are billing in their own offices for a 99213 or 99214!!

I get the feeling most people (and docs) are so busy that there is little time for reflection on these issues and comparing rates across regions, insurers, states. We do not generally have extra time on our hands like the executives who apparently do and set the rules we live by...

Again, I feel it is a luxury that I can even sit back and contemplate politics, the business of medicine and transforming health care in this country.

Pamela

That’s great for you if it is true, but why are you the only one I’ve ever heard say this? Even other doctors from your area do not seem to confirm this extraordinary reimbursement, but maybe they are trying to be more secretive about it. Does your ex-partner you mentioned work nearby? If so, why is he unable to duplicate those rates? Also, I’ve looked at a few job postings for family docs in your neck of the woods & they do not mention the greatly different reimbursement, and the high starting salaries seem pretty typical (even a bit below average if anything).. I just find it hard to fathom that the upper mgt at those local insurances do not realize that they could pay you 50% less & easily get away with it, especially since that is what all of their competitors are doing all across the country. Hard to believe, but great for you though if accurate.

-----Original Message-----From: [mailto: ] On Behalf Of pamela wibleSent: Wednesday, March 22, 2006 12:42 PMTo: Subject: Re: REIMBURSEMENT "MICROCLIMATES"

,

On reimbursement - nothing unusual about my codes. I am submitting what most other folks are on this list - more 99214s than 13s and rare 212s, 10% or less 99215s and then the CPX codes of course. ICD9s are the standard ya know 401.1 for HTN, 272.0 high chol etc...etc..

Nothing fishy. no strange codes or magic spells.

I happen to be in what I call " a high reimbursement microclimate"

I think there are extremely great and extremely horrible "microclimates" for malpractice as well. I do not know how or why or who decides these things. Some guy in an office somewhere plays with #s I guess....

I am getting 85-100% of the billed fee by insurers generally. People say if I am getting 100% of my billed fee from insurers I should charge more. I think it would be highway robbery if I charged more as I already get 134-167 on my 99214s.

Don't ask me why. I do not know ...??? Does anyone??

Pamela

Pamela Wible, MD

Family & Community Medicine, LLC

3575 st. #220

Eugene, OR 97405

roxywible@...

www.idealmedicalpractice.org

Yes I too have had the same question as to how you can average $112 per visit when most docs are averaging around $50/visit & of us those using EMR’s are about $75-$80/visit. It still makes me wonder if you are inadvertently submitting visits under a specialist code, hospital place of service, something to cause a drastically higher reimbursement. I recall the example of another doc on the list that was getting reimbursed something like $30+ for “venipuncture” vs the normal $3. It was then discovered that she was submitting those as “therapeutic phlebotomy” codes rather than standard venipuncture (oops). I just keep hearing the old adage in my head: if it sounds too good to be true, then it usually is. Oh well, I can’t spend too much mental energy wondering about other doc’s practices but it still makes me say: hmmm how can that be?

-----Original Message-----From: [mailto: ] On Behalf Of pamela wibleSent: Wednesday, March 22, 2006 11:19 AMTo: Subject: Re: Re: what do doctors actually do

Yes! Agree! It is SPIRITUAL our work.

Analogy: Can you imagine a priest inserting the following folks between himself and his suffering client:

nurse

secretary

insurance agent

pharmacy rep

EMR techie

CPA

Attorney

and then helping the client and managing the crowd above concurrently???

We are healers. It is spiritual work. It is an honor.

Our profession is degraded when money is the bottom line, speed/productivity is rewarded and countless people are shoved between ourselves and our patient.

I spoke to my prior employer last night who I have a lot of respect for (even though he would have kept my bonus had I not pursued it). He was intrigued by my financial #s regarding my current LOVE (Low Overhead Volume) model and his HOVE (high overhead volume) model.

He wanted to clarify that I really bring in $112 or so per pt on average without "ancillaries" and I believe my "ancillaries" that I end up charging for (by time - more 99214s) are in the realm of spirituality, not an unnecessary set of labs or EKG (these thing were overordered at that clinic for $$$).

Testing has its place. Most folks come for healing and that is beyond the physical realm most of the time.

Regarding $$$$ and the bottom line, my prior employer (near partner had I stayed) said that I would be making around 360K (like him) had I stayed with them as my #s were close to his on productivity. He did understand why the LOVE model appealed to me though. I told him not all docs can see thrive in his model and he concurred. It takes a certain personailty, charisma, skill to see high numbers of patients well and remain balanced as a human being. We certainly are not providing for their spiritual needs in 10 minute visits with ancillary staff running in and out of the room and EKG machines beeping away in a frenzied atmosphere. I just do not see it happening.

Our work is at its foundation - spiritual.

Pamela

Pamela Wible, MD

Family & Community Medicine, LLC

3575 st. #220

Eugene, OR 97405

roxywible@...

www.idealmedicalpractice.org

At the risk of coming across as too heavy-duty, here are my thoughts on this topic:Our connection with each other--patients, family, colleagues, etc.--is beyond what is physical. We serve a source that is unaffected by what happens to our bodies, our lives. There is a level of energy, for lack of a better word, that we sort of float over during the business of our lives. If we can teach ourselves to quiet down our minds and allow that energy to rise, we can feel that source. It is limitless, joyful and does not change based on what is happening to us.It is precisely the sense of disconnection to this source why our spiritual brothers and sisters seek our services in our clinics. I believe that a slowed-down practice is more likely able to minister to their spiritual wounds. But only if we our relatively healed ourselves. This is, I believe, a part of our quest--to help elevate each other, or, more accurately, lower each other to feel that connection and influence a slight change. The change is an enhancement of our conscious selves to feel our deeper selves. Self-awareness. Prayer, meditation, art, work, whatever we lose ourselves in and feel joy through.Our role as physicians is just that: a role.We are infinitely more. Our other task is to discover that and celebrate it. And to influence others to feel it, too.I had a dream when I was 17 years old where I was told this exact message. There were 30 other people in the same room. Any of you out there?Occasionally, rarely, I sense with my patients that we were lead to each other so that this process can happen. When this takes place, my role as physician, acupuncturist, etc. suddenly feels unimportant. And the connection I share with them gives me the reassurance that I am in the right place at the right time. I trust that I am doing my best, and then I want to go to sleep. Feels good.CharlieNew Mountain Medicinelin, NCDate: Tue Mar 21 21:37:47 CST 2006To: Subject: Re: what do doctors actually doYour last line struck me as so true. Let's not consider ourselves more important than we actually are. I have been in the business for 15 plus years and have probably truly saved in way of lives 30-50. Maybe more, it is a hard thing to measure. Would these people be there if I had not, maybe not, maybe so. What we do in primary care is hard to put a value on in many ways. How many amputations or heart attacks have I prevented? How many caused? How many have I prevented from going on dialysis? How many strokes prevented? I have no way of knowing. If we take credit for every success , we must stare every failure in the face and also acknowledge that. I believe it is better to be very humble in our dealings with patients.Brent > >>>> >>> >>>> >> i've been reading about the social burden of being a doctor and> >>>> > how it relates to low overhead practice with great interest.> >>>> >>> >>>> >>  there are some underlying fundamental precepts i like to keep > >>>> in> >>>> > mind when discussing these things.> >>>> >>> >>>> >>  they are:> >>>> >>> >>>> >>  health care is not a right or privilege; it is a basic human> >>>> > need, just like food, clothing and shelter. everybody needs it.> >>>> >>> >>>> >>  good health care arises from a healthy doctor-patient> >>>> > relationship. the relationship facilitates healthy choices> >>>> > resulting in good outcomes.> >>>> >>> >>>> >>  any framework surrounding the doctor-patient relationship must> >>>> > be defined by the needs of the doctor-patient relationship. form> >>>> > follows function.> >>>> >>> >>>> >>  just my thoughts.> >>>> >>> >>>> >>  LL> >>>> >>> >>>> >>> >>>> >> ---------------------------------> >>>> >> Yahoo! Travel> >>>> >> Find great deals to the top 10 hottest destinations!> >>>> >>> >>>> >> >>>> >> >>>> >> >>>> >> >>>> >> >>>> >> >>>> >> >>>> >

[Guest guest]

Hi all-

We are north of Pamela in Vancouver,

Washington just across the Columbia River from Portland, Oregon.  We bill out

about avg. $150 per visit ($65 per RBRVU) and get back between $130-150 per

visit from most of our commercial payors.  (State and Medicare would be closer

to $85.)  Our “microclimate” is at least one county in Washington and three in Oregon.  We have IPA’s in our area

that are effective at negotiating and represent most of the doctors in our

area.  (One in Washington and at least three on the Oregon side.)

For example, we independently tried to

negotiate with a commercial payer by ourselves.  The best offer we got was $40

per RBRBU.  We turned them down.  A few months latter our IPA announced they

had reached an agreement with them.  It is for $62 per RBRVU.  There is power

in numbers.  If your area has an IPA consider joining it.  Ours costs $1000 to

join and $300(?) per year.  We made it up in the first month.  Even if they don’t

have much better contracts, consider joining and encouraging others to join.  If

it represents most of the doctors in your area, the next contracts could be

much better.  (I don’t understand the legalities of the IPA’s. 

They are legal, but I am not sure why they are or why they would not be.)

Another way to help raise reimbursements

is to drop insurers who pay poorly or add excessive administrative burden.  If

you drop them and others drop them they will be forced to be raise their

reimbursement and/or drop their referrals/pain in the neck billing

policies/whatever else is a pain.  If you do drop them, call your provider rep

and let them know why.  If they have ten docs from your area call and drop due

to bad reimbursement, it may lead them to increase their reimbursement.

Our area is also growing, creating some

pressure for more doctors, but I don’t think you could define it as

difficult to get a doctor unless you have state insurance.

Ernie

From:

[mailto: ]

On Behalf Of pamela wible

Sent: Wednesday, March 22, 2006

12:48 PM

To:

Subject: Re:

REIMBURSEMENT " MICROCLIMATES "

Believe me, the large groups which dominate my county (one large 100

doc group and another with 80 docs) rake it in I'm sure. It just doesn't

trickle down to the docs who are employees unless they are productivity hounds.

Their starting salaries are comparatively low to other regions such as the SE USA for example.

I think many docs in solo practice or small groups

have been here for decades and I am not sure they communicate about this with

others in Ohio

or elsewhere. I think it is a luxury that I even have time to contemplate

any of this as most of my colleagues are " wheel to the grindstone " or

whatever the phrase is. I mean isn't it illegal to compare rates anyway??

The other doc (my prior employer) is in Washington state - Olympia

and I think he says they charge 109 for their 99214 and never come close to getting

full payment from insurers often.He is a volume guy and gets his 360K on really

high volume with tons of ancillaries. Another partner in the group can barely

get over 90K and works his butt off seeing 21-22 pts/day. Overhead there

requires one to get to 18/per day.

So, why me? I do not know. Maybe I have

a guardian angel? Maybe I am floating on the coattails of the large groups that

must work hand and hand with the large insurers regionally and secretly

(somehow) increase the rates. I really have no idea. I am BTW an open book sort

of person and I share details openly and freely.

I do not know if others are secretive, unaware of

the discrepancies, or just so busy (most employed docs) and they do not even

know what they are billing!!!! Most docs who are employees seem so hands

off on the business of medicine they really get their info from reading the

newspaper. They read about the malpractice crisis, yet have NO IDEA what

they pay (via their large group) for malpractice. They read about uninsured

poor people, but have no idea what they are billing in their own offices for a

99213 or 99214!!

I get the feeling most people (and docs) are so busy

that there is little time for reflection on these issues and comparing rates

across regions, insurers, states. We do not generally have extra time on

our hands like the executives who apparently do and set the rules we live by...

Again, I feel it is a luxury that I can even sit

back and contemplate politics, the business of medicine and transforming health

care in this country.

Pamela

That’s great for you if it is true, but why are you the only

one I’ve ever heard say this? Even other doctors from your area do

not seem to confirm this extraordinary reimbursement, but maybe they are trying

to be more secretive about it. Does your ex-partner you mentioned work

nearby? If so, why is he unable to duplicate those rates? Also,

I’ve looked at a few job postings for family docs in your neck of the

woods & they do not mention the greatly different reimbursement, and the

high starting salaries seem pretty typical (even a bit below average if

anything).. I just find it hard to fathom that the upper mgt at those

local insurances do not realize that they could pay you 50% less & easily

get away with it, especially since that is what all of their competitors are

doing all across the country. Hard to believe, but great for you though

if accurate.

-----Original

Message-----

From:

[mailto: ]

On Behalf Of pamela wible

Sent: Wednesday, March 22, 2006

12:42 PM

To:

Subject: Re:

REIMBURSEMENT " MICROCLIMATES "

,

On reimbursement -

nothing unusual about my codes. I am submitting what most other folks are

on this list - more 99214s than 13s and rare 212s, 10% or less 99215s and then

the CPX codes of course. ICD9s are the standard ya know 401.1 for HTN,

272.0 high chol etc...etc..

Nothing fishy. no

strange codes or magic spells.

I happen to be in

what I call " a high reimbursement microclimate "

I think there are

extremely great and extremely horrible " microclimates " for

malpractice as well. I do not know how or why or who decides these

things. Some guy in an office somewhere plays with #s I guess....

I am getting

85-100% of the billed fee by insurers generally. People say if I am getting

100% of my billed fee from insurers I should charge more. I think it

would be highway robbery if I charged more as I already get 134-167 on my

99214s.

Don't ask me

why. I do not know ...??? Does anyone??

Pamela

Pamela Wible, MD

Family & Community Medicine, LLC

3575 st. #220

Eugene, OR 97405

roxywible@...

www.idealmedicalpractice.org

On Mar 22, 2006,

at 8:51 AM, Brock DO wrote:

Yes I too have had the same question as to how you can average $112

per visit when most docs are averaging around $50/visit & of us those using

EMR’s are about $75-$80/visit. It still makes me wonder if you are

inadvertently submitting visits under a specialist code, hospital place of

service, something to cause a drastically higher reimbursement. I recall

the example of another doc on the list that was getting reimbursed something

like $30+ for “venipuncture” vs the normal $3. It was then

discovered that she was submitting those as “therapeutic

phlebotomy” codes rather than standard venipuncture (oops). I just

keep hearing the old adage in my head: if it sounds too good to be true, then

it usually is. Oh well, I can’t spend too much mental energy wondering

about other doc’s practices but it still makes me say: hmmm how can

that be?

-----Original

Message-----

From:

[mailto: ]

On Behalf Of pamela wible

Sent: Wednesday, March 22, 2006

11:19 AM

To:

Subject: Re:

Re: what do doctors actually do

Yes!

Agree! It is SPIRITUAL our work.

Analogy: Can

you imagine a priest inserting the following folks between himself and his

suffering client:

nurse

secretary

insurance agent

pharmacy rep

EMR techie

CPA

Attorney

and then helping

the client and managing the crowd above concurrently???

We are

healers. It is spiritual work. It is an honor.

Our profession is

degraded when money is the bottom line, speed/productivity is rewarded and

countless people are shoved between ourselves and our patient.

I spoke to my

prior employer last night who I have a lot of respect for (even though he would

have kept my bonus had I not pursued it). He was intrigued by my

financial #s regarding my current LOVE (Low Overhead Volume) model and his HOVE (high overhead volume) model.

He wanted to

clarify that I really bring in $112 or so per pt on average without " ancillaries "

and I believe my " ancillaries " that I end up charging for (by time -

more 99214s) are in the realm of spirituality, not an unnecessary set of labs

or EKG (these thing were overordered at that clinic for $$$).

Testing has its

place. Most folks come for healing and that is beyond the physical realm

most of the time.

Regarding $$$$ and

the bottom line, my prior employer (near partner had I stayed) said that I

would be making around 360K (like him) had I stayed with them as my #s were

close to his on productivity. He did understand why the LOVE model appealed to

me though. I told him not all docs can see thrive in his model and he

concurred. It takes a certain personailty, charisma, skill to see high

numbers of patients well and remain balanced as a human being. We

certainly are not providing for their spiritual needs in 10 minute visits with

ancillary staff running in and out of the room and EKG machines beeping away in

a frenzied atmosphere. I just do not see it happening.

Our work is at its

foundation - spiritual.

Pamela

Pamela Wible, MD

Family & Community Medicine, LLC

3575 st. #220

Eugene, OR 97405

roxywible@...

www.idealmedicalpractice.org

On Mar 21, 2006,

at 8:31 PM,

wrote:

At the risk of coming across as too heavy-duty,

here are my thoughts on this topic:

Our connection with each other--patients, family,

colleagues, etc.--is beyond what is physical. We serve a source that is

unaffected by what happens to our bodies, our lives. There is a level of

energy, for lack of a better word, that we sort of float over during the

business of our lives. If we can teach ourselves to quiet down our minds and

allow that energy to rise, we can feel that source. It is limitless, joyful and

does not change based on what is happening to us.

It is precisely the sense of disconnection to this

source why our spiritual brothers and sisters seek our services in our clinics.

I believe that a slowed-down practice is more likely able to minister to their

spiritual wounds. But only if we our relatively healed ourselves. This is, I

believe, a part of our quest--to help elevate each other, or, more accurately,

lower each other to feel that connection and influence a slight change. The

change is an enhancement of our conscious selves to feel our deeper selves.

Self-awareness. Prayer, meditation, art, work, whatever we lose ourselves in

and feel joy through.

Our role as physicians is just that: a role.

We are infinitely more. Our other task is to

discover that and celebrate it. And to influence others to feel it, too.

I had a dream when I was 17 years old where I was

told this exact message. There were 30 other people in the same room. Any of

you out there?

Occasionally, rarely, I sense with my patients

that we were lead to each other so that this process can happen. When this

takes place, my role as physician, acupuncturist, etc. suddenly feels

unimportant. And the connection I share with them gives me the reassurance that

I am in the right place at the right time. I trust that I am doing my best, and

then I want to go to sleep. Feels good.

Charlie

New Mountain Medicine

lin, NC

Date: Tue Mar 21 21:37:47 CST 2006

To:

Subject: Re: what do

doctors actually do

Your last line struck me as so true. Let's

not consider ourselves

more important than we actually are.

I have been in the business for 15 plus

years and have probably

truly saved in way of lives 30-50. Maybe more, it

is a hard thing to

measure. Would these people be there if I

had not, maybe not, maybe

so.

What we do in primary care is hard to put a value

on in many ways.

How many amputations or heart attacks have I

prevented? How many

caused? How many have I prevented from going

on dialysis? How many

strokes prevented? I have no way of

knowing.

If we take credit for every success , we must

stare every failure in

the face and also acknowledge that. I

believe it is better to be

very humble in our dealings with patients.

Brent

> >>>> >>

> >>>> >> i've been reading

about the social burden of being a

doctor and

> >>>> > how it relates to low

overhead practice with great interest.

> >>>> >>

> >>>> >>Â Â there are

some underlying fundamental precepts i like

to keep

> >>>> in

> >>>> > mind when discussing

these things.

> >>>> >>

> >>>> >>Â Â they are:

> >>>> >>

> >>>> >>Â Â health

care is not a right or privilege; it is a basic

human

> >>>> > need, just like food,

clothing and shelter. everybody

needs it.

> >>>> >>

> >>>> >>Â Â good

health care arises from a healthy doctor-patient

> >>>> > relationship.Â

the relationship facilitates healthy choices

> >>>> > resulting in good

outcomes.

> >>>> >>

> >>>> >>Â Â any

framework surrounding the doctor-patient

relationship must

> >>>> > be defined by the needs

of the doctor-patient

relationship. form

> >>>> > follows function.

> >>>> >>

> >>>> >>Â Â just my

thoughts.

> >>>> >>

> >>>> >>Â Â LL

> >>>> >>

> >>>> >>

> >>>> >>

---------------------------------

> >>>> >> Yahoo! Travel

> >>>> >>Â FindÂ

great deals to the top 10 hottest destinations!

> >>>> >>

> >>>> >

> >>>> >

> >>>> >

> >>>> >

> >>>> >

> >>>> >

> >>>> >

> >>>> >

[Guest guest]

Hi all-

We are north of Pamela in Vancouver,

Washington just across the Columbia River from Portland, Oregon.  We bill out

about avg. $150 per visit ($65 per RBRVU) and get back between $130-150 per

visit from most of our commercial payors.  (State and Medicare would be closer

to $85.)  Our “microclimate” is at least one county in Washington and three in Oregon.  We have IPA’s in our area

that are effective at negotiating and represent most of the doctors in our

area.  (One in Washington and at least three on the Oregon side.)

For example, we independently tried to

negotiate with a commercial payer by ourselves.  The best offer we got was $40

per RBRBU.  We turned them down.  A few months latter our IPA announced they

had reached an agreement with them.  It is for $62 per RBRVU.  There is power

in numbers.  If your area has an IPA consider joining it.  Ours costs $1000 to

join and $300(?) per year.  We made it up in the first month.  Even if they don’t

have much better contracts, consider joining and encouraging others to join.  If

it represents most of the doctors in your area, the next contracts could be

much better.  (I don’t understand the legalities of the IPA’s. 

They are legal, but I am not sure why they are or why they would not be.)

Another way to help raise reimbursements

is to drop insurers who pay poorly or add excessive administrative burden.  If

you drop them and others drop them they will be forced to be raise their

reimbursement and/or drop their referrals/pain in the neck billing

policies/whatever else is a pain.  If you do drop them, call your provider rep

and let them know why.  If they have ten docs from your area call and drop due

to bad reimbursement, it may lead them to increase their reimbursement.

Our area is also growing, creating some

pressure for more doctors, but I don’t think you could define it as

difficult to get a doctor unless you have state insurance.

Ernie

From:

[mailto: ]

On Behalf Of pamela wible

Sent: Wednesday, March 22, 2006

12:48 PM

To:

Subject: Re:

REIMBURSEMENT " MICROCLIMATES "

Believe me, the large groups which dominate my county (one large 100

doc group and another with 80 docs) rake it in I'm sure. It just doesn't

trickle down to the docs who are employees unless they are productivity hounds.

Their starting salaries are comparatively low to other regions such as the SE USA for example.

I think many docs in solo practice or small groups

have been here for decades and I am not sure they communicate about this with

others in Ohio

or elsewhere. I think it is a luxury that I even have time to contemplate

any of this as most of my colleagues are " wheel to the grindstone " or

whatever the phrase is. I mean isn't it illegal to compare rates anyway??

The other doc (my prior employer) is in Washington state - Olympia

and I think he says they charge 109 for their 99214 and never come close to getting

full payment from insurers often.He is a volume guy and gets his 360K on really

high volume with tons of ancillaries. Another partner in the group can barely

get over 90K and works his butt off seeing 21-22 pts/day. Overhead there

requires one to get to 18/per day.

So, why me? I do not know. Maybe I have

a guardian angel? Maybe I am floating on the coattails of the large groups that

must work hand and hand with the large insurers regionally and secretly

(somehow) increase the rates. I really have no idea. I am BTW an open book sort

of person and I share details openly and freely.

I do not know if others are secretive, unaware of

the discrepancies, or just so busy (most employed docs) and they do not even

know what they are billing!!!! Most docs who are employees seem so hands

off on the business of medicine they really get their info from reading the

newspaper. They read about the malpractice crisis, yet have NO IDEA what

they pay (via their large group) for malpractice. They read about uninsured

poor people, but have no idea what they are billing in their own offices for a

99213 or 99214!!

I get the feeling most people (and docs) are so busy

that there is little time for reflection on these issues and comparing rates

across regions, insurers, states. We do not generally have extra time on

our hands like the executives who apparently do and set the rules we live by...

Again, I feel it is a luxury that I can even sit

back and contemplate politics, the business of medicine and transforming health

care in this country.

Pamela

That’s great for you if it is true, but why are you the only

one I’ve ever heard say this? Even other doctors from your area do

not seem to confirm this extraordinary reimbursement, but maybe they are trying

to be more secretive about it. Does your ex-partner you mentioned work

nearby? If so, why is he unable to duplicate those rates? Also,

I’ve looked at a few job postings for family docs in your neck of the

woods & they do not mention the greatly different reimbursement, and the

high starting salaries seem pretty typical (even a bit below average if

anything).. I just find it hard to fathom that the upper mgt at those

local insurances do not realize that they could pay you 50% less & easily

get away with it, especially since that is what all of their competitors are

doing all across the country. Hard to believe, but great for you though

if accurate.

-----Original

Message-----

From:

[mailto: ]

On Behalf Of pamela wible

Sent: Wednesday, March 22, 2006

12:42 PM

To:

Subject: Re:

REIMBURSEMENT " MICROCLIMATES "

,

On reimbursement -

nothing unusual about my codes. I am submitting what most other folks are

on this list - more 99214s than 13s and rare 212s, 10% or less 99215s and then

the CPX codes of course. ICD9s are the standard ya know 401.1 for HTN,

272.0 high chol etc...etc..

Nothing fishy. no

strange codes or magic spells.

I happen to be in

what I call " a high reimbursement microclimate "

I think there are

extremely great and extremely horrible " microclimates " for

malpractice as well. I do not know how or why or who decides these

things. Some guy in an office somewhere plays with #s I guess....

I am getting

85-100% of the billed fee by insurers generally. People say if I am getting

100% of my billed fee from insurers I should charge more. I think it

would be highway robbery if I charged more as I already get 134-167 on my

99214s.

Don't ask me

why. I do not know ...??? Does anyone??

Pamela

Pamela Wible, MD

Family & Community Medicine, LLC

3575 st. #220

Eugene, OR 97405

roxywible@...

www.idealmedicalpractice.org

On Mar 22, 2006,

at 8:51 AM, Brock DO wrote:

Yes I too have had the same question as to how you can average $112

per visit when most docs are averaging around $50/visit & of us those using

EMR’s are about $75-$80/visit. It still makes me wonder if you are

inadvertently submitting visits under a specialist code, hospital place of

service, something to cause a drastically higher reimbursement. I recall

the example of another doc on the list that was getting reimbursed something

like $30+ for “venipuncture” vs the normal $3. It was then

discovered that she was submitting those as “therapeutic

phlebotomy” codes rather than standard venipuncture (oops). I just

keep hearing the old adage in my head: if it sounds too good to be true, then

it usually is. Oh well, I can’t spend too much mental energy wondering

about other doc’s practices but it still makes me say: hmmm how can

that be?

-----Original

Message-----

From:

[mailto: ]

On Behalf Of pamela wible

Sent: Wednesday, March 22, 2006

11:19 AM

To:

Subject: Re:

Re: what do doctors actually do

Yes!

Agree! It is SPIRITUAL our work.

Analogy: Can

you imagine a priest inserting the following folks between himself and his

suffering client:

nurse

secretary

insurance agent

pharmacy rep

EMR techie

CPA

Attorney

and then helping

the client and managing the crowd above concurrently???

We are

healers. It is spiritual work. It is an honor.

Our profession is

degraded when money is the bottom line, speed/productivity is rewarded and

countless people are shoved between ourselves and our patient.

I spoke to my

prior employer last night who I have a lot of respect for (even though he would

have kept my bonus had I not pursued it). He was intrigued by my

financial #s regarding my current LOVE (Low Overhead Volume) model and his HOVE (high overhead volume) model.

He wanted to

clarify that I really bring in $112 or so per pt on average without " ancillaries "

and I believe my " ancillaries " that I end up charging for (by time -

more 99214s) are in the realm of spirituality, not an unnecessary set of labs

or EKG (these thing were overordered at that clinic for $$$).

Testing has its

place. Most folks come for healing and that is beyond the physical realm

most of the time.

Regarding $$$$ and

the bottom line, my prior employer (near partner had I stayed) said that I

would be making around 360K (like him) had I stayed with them as my #s were

close to his on productivity. He did understand why the LOVE model appealed to

me though. I told him not all docs can see thrive in his model and he

concurred. It takes a certain personailty, charisma, skill to see high

numbers of patients well and remain balanced as a human being. We

certainly are not providing for their spiritual needs in 10 minute visits with

ancillary staff running in and out of the room and EKG machines beeping away in

a frenzied atmosphere. I just do not see it happening.

Our work is at its

foundation - spiritual.

Pamela

Pamela Wible, MD

Family & Community Medicine, LLC

3575 st. #220

Eugene, OR 97405

roxywible@...

www.idealmedicalpractice.org

On Mar 21, 2006,

at 8:31 PM,

wrote:

At the risk of coming across as too heavy-duty,

here are my thoughts on this topic:

Our connection with each other--patients, family,

colleagues, etc.--is beyond what is physical. We serve a source that is

unaffected by what happens to our bodies, our lives. There is a level of

energy, for lack of a better word, that we sort of float over during the

business of our lives. If we can teach ourselves to quiet down our minds and

allow that energy to rise, we can feel that source. It is limitless, joyful and

does not change based on what is happening to us.

It is precisely the sense of disconnection to this

source why our spiritual brothers and sisters seek our services in our clinics.

I believe that a slowed-down practice is more likely able to minister to their

spiritual wounds. But only if we our relatively healed ourselves. This is, I

believe, a part of our quest--to help elevate each other, or, more accurately,

lower each other to feel that connection and influence a slight change. The

change is an enhancement of our conscious selves to feel our deeper selves.

Self-awareness. Prayer, meditation, art, work, whatever we lose ourselves in

and feel joy through.

Our role as physicians is just that: a role.

We are infinitely more. Our other task is to

discover that and celebrate it. And to influence others to feel it, too.

I had a dream when I was 17 years old where I was

told this exact message. There were 30 other people in the same room. Any of

you out there?

Occasionally, rarely, I sense with my patients

that we were lead to each other so that this process can happen. When this

takes place, my role as physician, acupuncturist, etc. suddenly feels

unimportant. And the connection I share with them gives me the reassurance that

I am in the right place at the right time. I trust that I am doing my best, and

then I want to go to sleep. Feels good.

Charlie

New Mountain Medicine

lin, NC

Date: Tue Mar 21 21:37:47 CST 2006

To:

Subject: Re: what do

doctors actually do

Your last line struck me as so true. Let's

not consider ourselves

more important than we actually are.

I have been in the business for 15 plus

years and have probably

truly saved in way of lives 30-50. Maybe more, it

is a hard thing to

measure. Would these people be there if I

had not, maybe not, maybe

so.

What we do in primary care is hard to put a value

on in many ways.

How many amputations or heart attacks have I

prevented? How many

caused? How many have I prevented from going

on dialysis? How many

strokes prevented? I have no way of

knowing.

If we take credit for every success , we must

stare every failure in

the face and also acknowledge that. I

believe it is better to be

very humble in our dealings with patients.

Brent

> >>>> >>

> >>>> >> i've been reading

about the social burden of being a

doctor and

> >>>> > how it relates to low

overhead practice with great interest.

> >>>> >>

> >>>> >>Â Â there are

some underlying fundamental precepts i like

to keep

> >>>> in

> >>>> > mind when discussing

these things.

> >>>> >>

> >>>> >>Â Â they are:

> >>>> >>

> >>>> >>Â Â health

care is not a right or privilege; it is a basic

human

> >>>> > need, just like food,

clothing and shelter. everybody

needs it.

> >>>> >>

> >>>> >>Â Â good

health care arises from a healthy doctor-patient

> >>>> > relationship.Â

the relationship facilitates healthy choices

> >>>> > resulting in good

outcomes.

> >>>> >>

> >>>> >>Â Â any

framework surrounding the doctor-patient

relationship must

> >>>> > be defined by the needs

of the doctor-patient

relationship. form

> >>>> > follows function.

> >>>> >>

> >>>> >>Â Â just my

thoughts.

> >>>> >>

> >>>> >>Â Â LL

> >>>> >>

> >>>> >>

> >>>> >>

---------------------------------

> >>>> >> Yahoo! Travel

> >>>> >>Â FindÂ

great deals to the top 10 hottest destinations!

> >>>> >>

> >>>> >

> >>>> >

> >>>> >

> >>>> >

> >>>> >

> >>>> >

> >>>> >

> >>>> >

[Guest guest]

We do not have it nearly that good hear in

central Ohio.  Consider yourself very lucky.  We don’t get anywhere near

that much here.  I don’t know of any IPA here.  I have not taken Anthem

or Cigna because of their blending/bundling/horrible reimbursement practices.  Also,

I find it interesting that you quote payments in RBRVU.  I never really hear

those used.

Re: what do

doctors actually do

Your last line struck me as so true. Let's

not consider ourselves

more important than we actually are.

I have been in the business for 15 plus

years and have probably

truly saved in way of lives 30-50. Maybe more, it

is a hard thing to

measure. Would these people be there if I

had not, maybe not, maybe

so.

What we do in primary care is hard to put a value

on in many ways.

How many amputations or heart attacks have I

prevented? How many

caused? How many have I prevented from going

on dialysis? How many

strokes prevented? I have no way of

knowing.

If we take credit for every success , we must

stare every failure in

the face and also acknowledge that. I

believe it is better to be

very humble in our dealings with patients.

Brent

> >>>> >>

> >>>> >> i've been reading

about the social burden of being a

doctor and

> >>>> > how it relates to low

overhead practice with great interest.

> >>>> >>

> >>>> >>Â Â there are

some underlying fundamental precepts i like

to keep

> >>>> in

> >>>> > mind when discussing

these things.

> >>>> >>

> >>>> >>Â Â they are:

> >>>> >>

> >>>> >>Â Â health

care is not a right or privilege; it is a basic

human

> >>>> > need, just like food,

clothing and shelter. everybody

needs it.

> >>>> >>

> >>>> >>Â Â good

health care arises from a healthy doctor-patient

> >>>> > relationship.Â

the relationship facilitates healthy choices

> >>>> > resulting in good

outcomes.

> >>>> >>

> >>>> >>Â Â any

framework surrounding the doctor-patient

relationship must

> >>>> > be defined by the needs

of the doctor-patient

relationship. form

> >>>> > follows function.

> >>>> >>

> >>>> >>Â Â just my

thoughts.

> >>>> >>

> >>>> >>Â Â LL

> >>>> >>

> >>>> >>

> >>>> >>

---------------------------------

> >>>> >> Yahoo! Travel

> >>>> >>Â FindÂ

great deals to the top 10 hottest destinations!

> >>>> >>

> >>>> >

> >>>> >

> >>>> >

> >>>> >

> >>>> >

> >>>> >

> >>>> >

> >>>> >