Pediatrics in a Medicaid environment
A day of a pediatric practice dealing with NJ medicaid HMO's.
I have been in practice for 25 years in NJ. I have spoken to numerous physicians, administrators and academicians about practice management. No 2 will give you the same advice, and to top it off all the articles in journals and webinars are relevant to practices that are largely third party payor supported.
My practice is a majority medicaid inner city practice. Here are my 2 cents worth on the daily issues in our practice.
To start " what was good yesterday is not the same today". When patients show up for their visit you need to check eligibility at that time, invariably that is a 5 min procedure. Then if the dial in verification does not work then you have to call the HMO and get a person on line now its a 15-30 min procedure. Ifs to come another day.
Well lets say the patient gets through step 1 and the insurance is certified for this visit.
Lets get to step 2. Reviewing chart information for past medical history. If the patient has always been in your practice thats great you have the information. If they have moved from city to city or doctor to doctor, you are at the mercy of the family for good history. In New Jersey we have a mandated Immunization Information Service, so you should have the immunization history. If you have a child in foster care there is even less family or past medical history.
Step 3 during the visit we need to be aware of the social history, family situation, home situation, availability of transportation for referral visit, medical formulary of the insurance before writing scripts. Which lab does the HMO participate with? what is the level of education of the parent, what are the support systems that are available to the family. Who are the caregivers of the child.
Step 4 does the child need followup in my office? Is there a referral needed? who are the specialists that participate in the plan? is the medication you want to prescribe covered?
Pitfalls
Anecdotally no shows are much higher in medicaid practices, there is no penalty for no shows. Contact information is less reliable, ER utilization rates are significantly higher in the medicaid population. PCP verification and eligibility in plans are less reliable at the beginning of the month.
Formularies are very restricted in Medicaid HMO's.
Now lets talk billing.
CPT and ICD codes are more relevant to adult practices than pediatrics. Medicaid (HMO plans) do not accept all codes in the book. Each plan has codes that they dictate be used for reimbursement, even so far as to create their own codes. Medicaid HMO's do not reimburse for everything that third party payors pay for.
Reimbursement rates in NJ for medicaid are approximately 45% of Medicare rates. During the 2 years of ACA parity PCP's saw productivity improve, morale improved, practices recruited extra providers to cover the participants. the PCP listed is not you then maybe you will get a nice representative who will retroactively allow you to see the patient, if not you have to send a unhappy family to reschedule a visit. Of course now you have a family that is financially challenged to spend bus fare or taxi fare or car expense
I have been in practice for 25 years in NJ. I have spoken to numerous physicians, administrators and academicians about practice management. No 2 will give you the same advice, and to top it off all the articles in journals and webinars are relevant to practices that are largely third party payor supported.
My practice is a majority medicaid inner city practice. Here are my 2 cents worth on the daily issues in our practice.
To start " what was good yesterday is not the same today". When patients show up for their visit you need to check eligibility at that time, invariably that is a 5 min procedure. Then if the dial in verification does not work then you have to call the HMO and get a person on line now its a 15-30 min procedure. Ifs to come another day.
Well lets say the patient gets through step 1 and the insurance is certified for this visit.
Lets get to step 2. Reviewing chart information for past medical history. If the patient has always been in your practice thats great you have the information. If they have moved from city to city or doctor to doctor, you are at the mercy of the family for good history. In New Jersey we have a mandated Immunization Information Service, so you should have the immunization history. If you have a child in foster care there is even less family or past medical history.
Step 3 during the visit we need to be aware of the social history, family situation, home situation, availability of transportation for referral visit, medical formulary of the insurance before writing scripts. Which lab does the HMO participate with? what is the level of education of the parent, what are the support systems that are available to the family. Who are the caregivers of the child.
Step 4 does the child need followup in my office? Is there a referral needed? who are the specialists that participate in the plan? is the medication you want to prescribe covered?
Pitfalls
Anecdotally no shows are much higher in medicaid practices, there is no penalty for no shows. Contact information is less reliable, ER utilization rates are significantly higher in the medicaid population. PCP verification and eligibility in plans are less reliable at the beginning of the month.
Formularies are very restricted in Medicaid HMO's.
Now lets talk billing.
CPT and ICD codes are more relevant to adult practices than pediatrics. Medicaid (HMO plans) do not accept all codes in the book. Each plan has codes that they dictate be used for reimbursement, even so far as to create their own codes. Medicaid HMO's do not reimburse for everything that third party payors pay for.
Reimbursement rates in NJ for medicaid are approximately 45% of Medicare rates. During the 2 years of ACA parity PCP's saw productivity improve, morale improved, practices recruited extra providers to cover the participants. the PCP listed is not you then maybe you will get a nice representative who will retroactively allow you to see the patient, if not you have to send a unhappy family to reschedule a visit. Of course now you have a family that is financially challenged to spend bus fare or taxi fare or car expense
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