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Making Cents of Reimbursements Chris Sipe, MD Fertility Centers of Illinois Chicago and Oakbrook offices

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Page 1: Making Cents of Reimbursements Chris Sipe, MD Fertility Centers of Illinois Chicago and Oakbrook offices
Page 2: Making Cents of Reimbursements Chris Sipe, MD Fertility Centers of Illinois Chicago and Oakbrook offices

Making Cents of Reimbursements

Chris Sipe, MDFertility Centers of Illinois

Chicago and Oakbrook offices

Page 4: Making Cents of Reimbursements Chris Sipe, MD Fertility Centers of Illinois Chicago and Oakbrook offices

How are REIs reimbursed

No fertility coverage, i.e. Self-pay Insurance

– Maximums, benefits, rules– Employer dependent

Practice style– Private– Academic

Practice arrangement– Solo practitioner– Group Practice

Page 5: Making Cents of Reimbursements Chris Sipe, MD Fertility Centers of Illinois Chicago and Oakbrook offices

Private Practice Reimbursement- Self pay

Nurses/Staff

Rent/Utilities

Equipment

Supplies

Malpractice

Marketing

$

$$

Page 6: Making Cents of Reimbursements Chris Sipe, MD Fertility Centers of Illinois Chicago and Oakbrook offices

Private Practice Reimbursement- Insurance

Nurses/Staff

Rent/Utilities

Equipment

Supplies

Malpractice

Marketing

$

$$

Coders/Admin

$

Page 7: Making Cents of Reimbursements Chris Sipe, MD Fertility Centers of Illinois Chicago and Oakbrook offices

How does insurance work

Employer is required by law to offer insurance to Employees– Plan must follow all state and local insurance laws

Employer can chose to add or remove coverage to suit their needs– Add pregnancy rider, mental health, infertility

Employer contracts with an insurance company to gain access to preset prices and range of services for their employees– The insurer can be paid a set fee for year to provide all services

• Budget $1,000,000 if over insurance company covers– Or insurance can pass the bills onto the employer (self-Insured)

• All bills paid by employer- harder to budget

Page 8: Making Cents of Reimbursements Chris Sipe, MD Fertility Centers of Illinois Chicago and Oakbrook offices

How does insurance work

Medical offices use ICD 9 (soon to be 10) codes for listing diagnoses for patients.– Example: Endometriosis, Infertility, Abdominal Pain

This then determines what treatments can be covered by insurance for that code– Endometriosis Laparoscopy covered, BCP covered, but not trigger point inject

Medical offices then bill CPT codes to denote what work was done– Laparoscopy with fulguration of endometriosis

Insurance then pays Medical office negotiated price within 30-60 days

Page 9: Making Cents of Reimbursements Chris Sipe, MD Fertility Centers of Illinois Chicago and Oakbrook offices

Rules for coding

Every CPT has a description of what it includes Clinic CPT codes require documentation of elements that were done

– Time (state amount of time spent with patient)– 3 Components: History, Physical, Consult

Only 1 CPT code will be reimbursed at a time– Others may reimbursed, but at a lesser rate

TAKE A CODING CLASS

Page 10: Making Cents of Reimbursements Chris Sipe, MD Fertility Centers of Illinois Chicago and Oakbrook offices

How much does insurance pay

AMA determines Relative Value Units (RVU) for every procedure performed within every specialty that is reimbursable– Helps equate surgery to clinic reimbursement– 15minute consult with PCP is reimbursed differently from 15min with Cardiology

Insurance negotiates a price in a contract with each provider based on a conversion factor of the RVU– Medicare is the standard @ $35.28 per RVU– Some insurances force all providers to take the same reimbursement amount– “Carve-outs” special price for an individual provider due to his/her expertise

Whatever the agreed upon price a provider cannot charge the patient more

Page 11: Making Cents of Reimbursements Chris Sipe, MD Fertility Centers of Illinois Chicago and Oakbrook offices

Insurance Billing from employer/ee

Total cost to insure an employee/patient is $1000 per month– Patient pays $250 per month while her employer pays $750

Clinic charges $2000 for a medical procedure (Billings)– Insurance contract will pay $1500 for medical procedure– Clinic discounts fee $500

Patient has $1000 deductible as part of plan– So patient pays clinic $1000 and insurance pays clinic $500– Clinic receives $1500 (collections)– After expenses subtracted, left with $600 (Net Revenue)

Page 12: Making Cents of Reimbursements Chris Sipe, MD Fertility Centers of Illinois Chicago and Oakbrook offices

States with Infertility Mandates

15 States have enacted mandates about infertility Arkansas (Lifetime Max $15,000) California (offered, but coverage not guaranteed) Connecticut (4-6 IUIs, 2 IVF cycles) Hawaii (1 IVF) Illinois (4 IVF cycles) Louisiana (no coverage, but cannot refuse if preexisting) Maryland (3 IVF cycles) Massachusetts (IUI and IVF no limits, but rules)

Page 13: Making Cents of Reimbursements Chris Sipe, MD Fertility Centers of Illinois Chicago and Oakbrook offices

States with Infertility Mandates

Montana (HMO must cover infertility) New Jersey (up to 4 IVF cycles) New York (Diagnostic testing, but not treatment) Ohio (Diagnostic testing, but not treatment) Rhode Island (Lifetime max of $100,000) Texas (Employers can decide to offer coverage) West Virginia (requires HMOs to cover infertility services)

Only 8 states truly require IVF coverage for treatment

Page 14: Making Cents of Reimbursements Chris Sipe, MD Fertility Centers of Illinois Chicago and Oakbrook offices

NO THANKS, I’LL JUST GO INTO ACADEMICS

Page 15: Making Cents of Reimbursements Chris Sipe, MD Fertility Centers of Illinois Chicago and Oakbrook offices

Academic Practices

Traditionally rewarded for teaching and publishing research Grant money and protected research time Less emphasis on money earned for department

Evolving as reimbursement go down and research grants dry up

The Advent of the RVU

Page 16: Making Cents of Reimbursements Chris Sipe, MD Fertility Centers of Illinois Chicago and Oakbrook offices

RVU

Each hospital and department determine the relative value of an academician’s productivity

Example:– Lecture to Medical Student = 1 RVU– Director of residency = 100 RVU– Day in clinic = 5 RVU– Surgery = 2 RVU– Collections = 1 RVU per $1000 dollars

End of year RVU determine a possible bonus or next year’s pay

Page 17: Making Cents of Reimbursements Chris Sipe, MD Fertility Centers of Illinois Chicago and Oakbrook offices

Academic Reimbursement

Nurses/Staff

Rent/Utilities

Equipment

Supplies

Malpractice

Marketing

$

Coders/Admin

$$$

Dean’s Tax

ResidentsFellows

More Admin

Research Grants

Graduate Medical Education

Page 18: Making Cents of Reimbursements Chris Sipe, MD Fertility Centers of Illinois Chicago and Oakbrook offices

Academic Reimbursement

Not just an REI division Not just an OBGYN department Multispecialty Hospital

Hospital negotiates insurance contracts Hospital determines budgets

Page 19: Making Cents of Reimbursements Chris Sipe, MD Fertility Centers of Illinois Chicago and Oakbrook offices

Thanks for your attentionAny Questions?

[email protected]

Page 20: Making Cents of Reimbursements Chris Sipe, MD Fertility Centers of Illinois Chicago and Oakbrook offices