My doctor was paid $10. for......

[Villages PL]

....an office visit that was my semiannual check up. He went over the results of my blood test, we talked about it, he went to the computer to plan for my next blood test, and then cleaned some wax out of both ears.

In a letter I received from Freedom Health, it shows that he put in a charge of $203.00 dollars. But all they gave him was $10.

The nurse weighed me, took my blood pressure and pulse. She also asked a few standard questions. By the time the doctor pays her salary and the salary of a couple others plus other office expenses, how much do you figure he'll have left for himself out of $10. dollars?

[dbussone]

....an office visit that was my semiannual check up. He went over the results of my blood test, we talked about it, he went to the computer to plan for my next blood test, and then cleaned some wax out of both ears.

In a letter I received from Freedom Health, it shows that he put in a charge of $203.00 dollars. But all they gave him was $10.

The nurse weighed me, took my blood pressure and pulse. She also asked a few standard questions. By the time the doctor pays her salary and the salary of a couple others plus other office expenses, how much do you figure he'll have left for himself out of $10. dollars?

If you are enrolled in the HMO your physician likely receives a "per patient per month" payment for each individual under his/her care. The $10 payment is probably for some additionally recognized work approved by Freedom Health. If you are in the Medicare Advantage plan I would doubt your doc will participate in Freedom Health next year.

[gerryann]

If you are enrolled in the HMO your physician likely receives a "per patient per month" payment for each individual under his/her care. The $10 payment is probably for some additionally recognized work approved by Freedom Health. If you are in the Medicare Advantage plan I would doubt your doc will participate in Freedom Health next year.

Very correct. For every contract for HMO's, the doc receives a monthly check. You will also get inferior care when he/she knows they will get the check regardless of weather they see you or not. If one is with a private insurance company (secondary to Medicare) the doc might do a lot of add on's, cause he'll get paid for it.

I disagree that the doc will drop his contract with Freedom Health. The more HMO's , the more checks he receives. It's a sure thing.

Obviously, not all docs are out for strictly the money. I'm sure somewhere here in TV there are some truly caring docs.

[dbussone]

Very correct. For every contract for HMO's, the doc receives a monthly check. You will also get inferior care when he/she knows they will get the check regardless of weather they see you or not. If one is with a private insurance company (secondary to Medicare) the doc might do a lot of add on's, cause he'll get paid for it.

I disagree that the doc will drop his contract with Freedom Health. The more HMO's , the more checks he receives. It's a sure thing.

Obviously, not all docs are out for strictly the money. I'm sure somewhere here in TV there are some truly caring docs.

Just a minor correction. Freedom Health also has a Medicare Advantage plan (non HMO). If VPL is in that plan the doc will only get paid for the visit, not PPPM. If the doc only receives $10 for a visit I really don't think he'll stay with that plan for long.

[gerryann]

Just a minor correction. Freedom Health also has a Medicare Advantage plan (non HMO). If VPL is in that plan the doc will only get paid for the visit, not PPPM. If the doc only receives $10 for a visit I really don't think he'll stay with that plan for long.

I stand corrected....but I thought that Freedom Health Medicare Advantage Plan had only the one HMO plan (except for special needs).......therefore meaning you have to ONLY go to the Dr's in the plan. Is their another one?

[dbussone]

I stand corrected....but I thought that Freedom Health Medicare Advantage Plan had only the one HMO plan (except for special needs).......therefore meaning you have to ONLY go to the Dr's in the plan. Is their another one?

I thought Freedom also had a Medicare Advantage plan as well. But I've been wrong before!

[gerryann]

I thought Freedom also had a Medicare Advantage plan as well. But I've been wrong before!

They do have a medicare advantage plan. But I thought it was an hmo.

[dbussone]

They do have a medicare advantage plan. But I thought it was an hmo.

Advantage plans are more like traditional insurance, and typically are fee for service based. One of the ways an advantage plan saves money is by restricting your choice of docs and facilities. HMOs are much more inclusive in terms of what they cover, but they are very restrictive in terms of the physicians and facilities you can use. Typically a primary care doc holds the referral reigns, determining whether you need to see a specialist or not. Except for super sub specialists, docs and facilities are almost always paid for on a PPPM basis.

[blueash]

One other possibility, doctor billed for two services, an office visit and a minor procedure of cleaning ears. Insurance only allows one service to be paid and paid the ear clean service denying the office visit as unbundling. Doc should resubmit with correct modifier for separately identifiable service. Pure speculation

[fred53]

Very correct. For every contract for HMO's, the doc receives a monthly check. You will also get inferior care when he/she knows they will get the check regardless of weather they see you or not. If one is with a private insurance company (secondary to Medicare) the doc might do a lot of add on's, cause he'll get paid for it.

I disagree that the doc will drop his contract with Freedom Health. The more HMO's , the more checks he receives. It's a sure thing.

Obviously, not all docs are out for strictly the money. I'm sure somewhere here in TV there are some truly caring docs.

"You will also get inferior care when he/she knows they will get the check regardless of weather they see you or not"...

Not only do you not personally know this, but it bespeaks of a deeper problem you might have...oh and it's spelled "whether" not "weather" which of course is what happens to our atmosphere...

[dbussone]

One other possibility, doctor billed for two services, an office visit and a minor procedure of cleaning ears. Insurance only allows one service to be paid and paid the ear clean service denying the office visit as unbundling. Doc should resubmit with correct modifier for separately identifiable service. Pure speculation

Good point blueash.

[sunnyatlast]

And people wonder why doctors get fed up and go to direct primary care for a reasonable retainer fee, with NO involvement with public or private insurance octopus!!

An example....
Atlas MD | Wichita (http://www.atlas.md/wichita/)

[gerryann]

"oh and it's spelled "whether" not "weather" which of course is what happens to our atmosphere...

I'm sure glad we have you for correcting spelling.

[gerryann]

"You will also get inferior care when he/she knows they will get the check regardless of weather they see you or not"...

Not only do you not personally know this, but it bespeaks of a deeper problem you might have....

Actually I do personally know this. I have worked for more Dr's than you probably have seen in your lifetime.

I also wonder why you are on a public, friendly forum with nasty comments about my having a deeper problem. If you have an agenda or are just generally unhappy, it might be beneficial to stay off of a public forum.

[Barefoot]

Not only do you not personally know this, but it bespeaks of a deeper problem you might have...oh and it's spelled "whether" not "weather" which of course is what happens to our atmosphere...

Please play nice. :ohdear:

[dbussone]

They do have a medicare advantage plan. But I thought it was an hmo.


Gerryann - what do you think about blueash's post regarding coding? That seems plausible to me.

[gerryann]

Gerryann - what do you think about blueash's post regarding coding? That seems plausible to me.

Makes sense. When I worked with Medicare and submitted claims.....more often than not, claims were submitted, resubmitted and many times a third time. Medicare has always been a stickler with proper coding. And of course would only pay for one if only one code was allowed. However, when I was doing it, they allowed multiple Codes per visit. Not sure now if only one CPT is allowed.

[Villages PL]

Perhaps it may help to know that my insurance card says: Freedom Platinum Plan Rx (HMO)

Procedure..................Code...............Char ged.......................Paid

99397 PERIODI............C20................203.00...... ..................0.00
C PREVENTIVE
MED EST
PATIENT 65YRS&
OLDER

G8418 BMI DOC............391...............0.01..........ALL OWED 10.00........... PAID 10.00
BLW NML PARAM
& A F/U PLAN
IS DOCUMENTED

EOB Explanation:

391 Payment is fee schedule based

C20 "Capitated payment, no member liability"

[dbussone]

That helps immensely. A traditional HMO with capitation. As I guessed.

[gerryann]

I certainly could be wrong but, I believe CPT codes 99391 thru 99397 are currently NOT covered by Medicare. I would guess that if your Doc has a good insurance person, they will resubmit (legally) with a new acceptable code.

[Villages PL]

I just remembered something: I believe most HMOs like Freedom only offer one free checkup per year. Being that it was my doctor's idea to have me come in for 2 checkups, one is not paid for. (I don't need 2 checkups.) I wonder who pays for the blood work?

[dbussone]

[QUOTE=gerryann;1056710]I certainly could be wrong but, I believe CPT codes 99391 thru 99397 are currently NOT covered by Medicare. I would guess that if your Doc has a good insurance person, they will resubmit (legally) with a new acceptable code.[/

Gerryann- Why wouldn't Medicare cover that general range of codes.?

[gerryann]

Wish I knew. Medicare has some strange rules....I do know that.

[blueash]

thanks for posting your eob. What I would suggest this says is that certain services are covered under the monthly check that the insurance sends to your doctor whether (or weather) or not you are seen. Dr. X gets a check for having you on his panel. Now the periodic well exam is one of those services. So it is not that he is not being paid, he is expected to do well exams on you, as many as he thinks you need. So he is getting paid, just not as a fee for service.
The $10 payment is for recording your BMI and making a plan to address any nutritional concerns related to your BMI. I'm not sure why that would even be an additional payment so it is nice they gave that amount.
Does not seem to have been a charge listed for the ear cleaning.

[Villages PL]

thanks for posting your eob. What I would suggest this says is that certain services are covered under the monthly check that the insurance sends to your doctor whether (or weather) or not you are seen. Dr. X gets a check for having you on his panel. Now the periodic well exam is one of those services. So it is not that he is not being paid, he is expected to do well exams on you, as many as he thinks you need. So he is getting paid, just not as a fee for service.
The $10 payment is for recording your BMI and making a plan to address any nutritional concerns related to your BMI. I'm not sure why that would even be an additional payment so it is nice they gave that amount.
Does not seem to have been a charge listed for the ear cleaning.

Thanks for the information.

My BMI might not be where they want it to be. It's about 18 and I assume they might prefer 18.5, although they have never stated this. I'm getting full at every meal with all healthy foods. And I have a gerontologist's book to back me up stating that a BMI of 18 is ideal, assuming one gets optimal nutrition.

I hate to complicate things but I just realized that my doctor doesn't work alone. He belongs to a group known as "Florida Medical Associates". It's a professional corporation consisting of 12 doctors, according to their website. (I just checked the website for the first time.) There's a group picture in his office consisting of about 50 or more employees and he's in the picture. I believe he said it includes everyone who works for the organization. I just remembered him saying that a couple of weeks ago. I believe he's an employee of this organization. On their website it says they are looking for more doctors to join their group. It says that doctors only have to see about 20 patients per day so they have more time to spend with each patient.

Here's a link: About Florida Medical Associates (FMA) (http://fmahealth.com/aboutfma.htm)

I suppose it means he gets a salary. I wonder who owns Florida Medical Associates, could it be the corporation that owns the hospitals?

[Nightengale212]

Thanks for the information.

My BMI might not be where they want it to be. It's about 18 and I assume they might prefer 18.5, although they have never stated this. I'm getting full at every meal with all healthy foods. And I have a gerontologist's book to back me up stating that a BMI of 18 is ideal, assuming one gets optimal nutrition.

I hate to complicate things but I just realized that my doctor doesn't work alone. He belongs to a group known as "Florida Medical Associates". It's a professional corporation consisting of 12 doctors, according to their website. (I just checked the website for the first time.) There's a group picture in his office consisting of about 50 or more employees and he's in the picture. I believe he said it includes everyone who works for the organization. I just remembered him saying that a couple of weeks ago. I believe he's an employee of this organization. On their website it says they are looking for more doctors to join their group. It says that doctors only have to see about 20 patients per day so they have more time to spend with each patient.

Here's a link: About Florida Medical Associates (FMA) (http://fmahealth.com/aboutfma.htm)

I suppose it means he gets a salary. I wonder who owns Florida Medical Associates, could it be the corporation that owns the hospitals?

Thanks for providing the link where you receive Primary Care. Was just taking with a physician I work with in Primary Care at the VA and his wife dragged him on a TV Lifestyle visit last month kicking and screaming. He surprised himself by falling in love with the place and is seriously considering a move to TV when he retires in the near future. He would like to continue working part-time which this practice notes they hire part-time physicians. How ironic he even kept up his Florida license as he lived and worked in Naples some years back.

Will be passing on the link to him today :)