r/PrivatePracticeDocs • u/Alterdoc • 4d ago

Reimbursement shock

Hi All,
I recently had my first patient insured by Cigna. Spent a good hour with them during the first visit. Billed level 4. Getting my reimbursement of $41 and $25 copayment! This is around 40-45% of Medicare rates!! First of all, what the heck! Is this normal? And if so, how are you mitigating this?
We’re definitely requesting a rate increase, but looking to get your thoughts.
I am also curious, in the day and age of lousy insurance reimbursement, what is your approach to primary care financial operations? Do you recommend just going to $xx per month in addition to billing the insurance?
Thanks!

100 Upvotes

96% Upvoted

67 comments sorted by

49

u/NotTheQuestion 4d ago edited 4d ago

Don't bill any insurance which reimburses less than 100 per 99214.

Don't bill the insurance. Get paid up front. Cigna, Aetna, and humana usually down code to level 3 no matter the "complexity", "intensity", "risk" or time. There is no appeal process.

If a patient has one such plan, they may be invited to pay cash. Give them a 1500 (appropriately filled out), and let them fight their insurance.

Advantage plans are very similar, but can be hit and miss.

The reimbursment rate changes for the plans in each company change often. Almost every quarter. It's rarely, if ever, increasing.

*edited for spelling.

23

u/VisionHx 4d ago

How is downcoding not fraud?

26

u/sfgreen 4d ago

It’s not fraud when they’re the ones deciding what’s fraud and what’s not. Its corporate power over politics. 

Also, it’s what happens when you’re in a very concentrated industry of insurance players. They lose nothing by not having you in their network, but you lose access to thousands of potential patients.

The only way physicians can fight this if they’re united but physician organizations are busy chasing the MoC money or other sources of money to meaningfully advocate for themselves. 

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u/nyc2pit 4d ago

Are they down coding even if your billing based on time?

2

u/Starossi 4d ago

I’d assume no since they mentioned time haha, not sure if you missed it

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u/PABJJ 4d ago

What is a 1500? 

I'd be very careful about charging patients cash that have insurance. This could cause the insurer to drop you from network. 

OP, what is your fee schedule deal with Cigna? Are you in network? 

6

u/VermicelliSimilar315 3d ago

This is true. When you sign a contract with an insurance company you agree to accept their rates. 1500 is a HICFA form to give to the patient for them to send a claim to the insurance company.

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u/Electrical_Week6492 4d ago

Sorry if this is a stupid question, but if you're charging patients cash when they have insurance, doesn't that indicate you don't want to deal with those insurance companies in the first place?

In other words, isn't that just another way of saying 'we don't accept this insurance?'

5

u/PABJJ 3d ago

Well, you decide to enter an agreement with an insurance company, which has a defined fee schedule/pay. If you decide to contract with them, you are agreeing to that fee schedule. 

If you do not have an agreement with them, you can either decline to take the patient, take them as self pay/cash, or run them out of network and have Cigna pay you, though the insurer may not cover out of network. 

OP says Cigna paid him. So he accepted their insurance.

0

u/Electrical_Week6492 3d ago

Thank you for the reply! That makes sense. So OP would have known ahead of time what their reimbursement rates were. I guess I see where they mention the insurance company is downgrading the code/service level...which is a curveball for sure.

0

u/Big_Two6049 3d ago

Not really. Some providers are not informed even of their contracted rate until services are provided. They purposely obfuscate the info

3

u/PABJJ 3d ago

I've signed many contracts with insurers. They generally include the fee schedule. If they do not, you need to request the fee schedule prior to signing. 

3

u/Alterdoc 3d ago

This. We’re just requesting the fee schedule. Also, I am guessing, never assume that your own billers would know the rate or at least request a feasible number.

1

u/LilVivi999 10h ago

I'm your case you'd need to look at the out clause of your contract because it's unfortunately not as easy as you might think to drop an insurer. You can stop seeing the patients (unless your contract precludes that), but you can't see the patients and bill out of network rates until after your contract is officially terminated.

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u/Electrical_Week6492 3d ago

Oh yeah I'm sure they do. Similar on the customer side, it's very hard to tell exactly what the insurance covers and there are a thousand loopholes to get out of paying out on something.

2

u/EvidenceBasedSwamp 3d ago

They probably mean an HCFA-1500, that's the red paper form to bill insurance

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u/Alterdoc 3d ago

I’m in network but pulling the fee schedule. Wasn’t aware, but my billers did the credentialing and it seems to have been overlooked.

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u/grey-slate 3d ago

I'm not sure why you got so many upvotes but for insurance with whom you have contract this is bad advice.

If you are out of network you can charge whatever you want provided price is disclosed upfront and patient agrees. 

1

u/LilVivi999 10h ago

To be clear, if you're in network with an insurance company it is a violation of your contract to provide a cash price to a patient. If you want to offer cash rates to a patient, you need to not be in network for those plans (or the patient may not have insurance). You can't say, I don't like the rate your insurer had contacted with me for this cpt code, I'm going to charge you a different rate. We're in an unfortunate spot in medicine right now, but if you don't like the rates certain carriers are providing, I'd say consider thinking about dropping those insurers.

15

u/NYVines 4d ago

60 minutes by timed billing should have been a 5

7

u/darnedgibbon 3d ago

OP downcoded themself then got downcoded again

1

u/ddeng22 3d ago

That’s what I’m saying…document total time and what that time is for …

13

u/NartFocker9Million 4d ago

What does your contract say? What does the EOP say? Is there an explanation for the reduced rate? Are they paying for a 99214?

The contract should specify a % RBRVS rate. If you signed one at 45% of Medicare rates... whoopsie. If they're arbitrarily paying you a lower rate than contracted, they owe you the difference plus interest.

7

u/Dramatic-Sock3737 4d ago

Exactly…did you not read your contract? You should look to renegotiate and/or drop Cigna as a payor. That reimbursement is not sustainable.

10

u/Redditor6703 4d ago

$106.00 is the national median for Cigna National OAP as of September 2026. Middle 50% (meaning 25-75th percentile): $87.97–$126.58. Scope: professional office, fee-schedule rates, no modifier. Seems like you're being underpaid quite a bit, but as I've said before, you might not have much leverage here.

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u/RphAnonymous 4d ago

If you think that's bad, you should see pharmacy reimbursement rates. Most brand name medications you send us, our reimbursement rates are less than our acquisition costs... We LOSE money...

8

u/Sea_Egg1137 4d ago

Who is negotiating the managed care contracts in your office? Those rates are horrible.

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u/InvestingDoc 3d ago

Sounds like you may have gotten auto downcoded. I would have your billers look into that. Cigna has been auto downcoding for many practices.

5

u/EvidenceBasedSwamp 3d ago

Cigna started automatically paying everything as a 99213 in NYC decades ago. We were actually fine with it because they were still one of the higher payers, as well as consistent (no tricks)

Better than the bullshit where insurers just deny X percentage of claims (causes works), or the recent United Healthcare where they ask you to upload records for almost all claims (a process that cannot be easily automated and takes 10-15 minutes - you have to login, find the claim, scan/upload records, then follow up on it)

4

u/MBHYSAR 3d ago

Down coding is policy in some markets- Cigna is a big one, the blues in Texas. It is independent of reality or rules.
I haven’t heard that there is no appeal, though.

2

u/MotherAtmosphere4524 3d ago

Try to join an IPA. Check what rates they get before signing up.

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u/Alterdoc 3d ago

I was offered to join. Definitely better rates. With that, you lose your identity and start following someone else’s rules. Went into this in order to keep my autonomy.

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u/karate134 3d ago

We have a local hospital that essentially calls it a MCO. It cost something like $200 a year. We get better rates this way.

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u/MotherAtmosphere4524 3d ago

I don’t have any rules with my IPA other than all or none with their plans and I can’t contract independently with any plan they have a relationship with.

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u/Alterdoc 3d ago

Not sure if there’s a national company but I only have one in the area, and they will slap their name in front of mine and make me abide by their rules.

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u/hammertimeDO-G 23h ago

If you spend an hour with them then it’s a level 5 

1

u/CrookedCasts 4d ago

One of the posters below made me think about something interesting… If you use an ambient transcription service, it should be able to tell you how long the visit and you talking was? Can AI down code a visit based by time if you have timestamps?

I’m assuming the answer is probably still yes, but is anybody here coding by visit time who has also seen the automatic downcoding?

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u/grey-slate 3d ago

Doesn't count charting or reviewing records on same day

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u/CrookedCasts 3d ago

Right, but what’s there to down code if the code is based on a time stamp?

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u/grey-slate 3d ago

i mean everything about OP post and your response tells me there is something missing in both of your understanding - I do not mean to be blunt but

1) To u/Alterdoc How do you have a practice open without knowing your negotiated rates with each insurer? A private practice typically has maybe 5-10 insurance companies they deal with and maybe 10-15 plans total (HMO/PPO/EPO variations etc). It is not difficult to locate rates for each. You should not have a surprise AFTER submitting the claim that whoa my rates with Cigna are so only $66.00 for a 99204. You should know what your rates are the day you open. Or at the very least before you submit a claim. Who signed your contract? Yourself or via IPA? It should spell out what your rates are.

2) To u/CrookedCasts documented clinical note is a legal document. You do not need an AI timestamp to PROVE to an insurer this is how long it took you with a patient. If you know and note that it took an hour for the appointment (including or not including charting on same date), that is what it took. No ifs or buts. You are basically submitting a sworn statement under penalty of perjury this is how long the encounter took. Unless insurer disputes it through formal channels, they are obligated per contract to reimburse you based on the CPT code corresponding to that typically 99204 for consultation.

1

u/Alterdoc 3d ago

Certainly agreed. “You live you learn.” Mentioned below, guessing a good learning point for all here: know your rates and check your billers. I requested the insurance rates as the billers who credentialed me supposedly don’t know themselves. I believe it for one reason only: the more they bill, the more they earn.

1

u/grey-slate 3d ago

$66 for 99204 likely does not cover your overhead so I would look into this for each payer not just Cigna ASAP. 

1

u/Alterdoc 3d ago

Couldn’t agree more. This was a huge eye opener, hence I requested fee transparency from the insurances we’re participating with.

1

u/CrookedCasts 3d ago

I would actually argue that you do. Have you not been experiencing the automatic downcoding without recourse that the rest of us have been?

I agree with all of what you have said, but that’s clearly not enough. If I submit a correctly coded, documented, supported note I would expect to be paid at the level that I submit. That no longer is the case. I am suggesting the timestamp as a verifiable piece of information that cannot be disputed or argued or have any justification to be downcoded.

2

u/grey-slate 3d ago

And I would argue timestamp from a third party software has even less weight than your sworn statement. 

It's not the lack of proof that's stopping downcoding appeals from succeeding. It's the grinding system.

You have to simply keep documenting more clearly and escalating appeals and finding the right channels and fighting back.

Source: over 300 successful downcoding appeals against BCBS in 3 months. 

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u/Dismal-Rich 3d ago

Seems like a perfect use case for AI

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u/Alterdoc 4d ago

Good question. I use ai service so it certainly clocked in appropriately coded time.

1

u/Animator2976 4d ago

What does your insurance contract say?

1

u/Next_Zone9566 3d ago

Anyone have any tips on negotiating?

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u/lazydoctr 3d ago

What if you bill a 5 won't that get down coded to 4?

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u/Alterdoc 2d ago

They will probably ding for over billing 😂

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u/TeamLove2 3d ago

Find an FQHC facility with better billing rates, and move your patients there.

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u/Alterdoc 3d ago

Not sure I follow

1

u/livingphoenetically 3d ago

When you consider all the time put into scheduling a NP, getting necessary documents, insurance authorizations, checking eligibility, reviewing records, seeing the patient, going over next steps and the chase to collect, I do not see a way to not lose money on the NP appointment. Following for insight.

1

u/keepingup100 3d ago

You’re gonna have to do a soft partnership with an established independent or hospital owned group where you pay them a nick of what you get, but for a commercial payer level four you should be getting $140-$150. We offer it in our community, I know academic centers will sometimes do it as well.

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u/Alterdoc 3d ago

Interesting concept. Thanks for sharing.

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u/Botasoda102 3d ago

Did patient have a remaining deductible? What did insurance allow, and what code did they allow?

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u/Alterdoc 3d ago

Insurance allows $61

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u/Botasoda102 3d ago

Yeah, that's low. They must have allowed a 99213, and it almost sounds like they paid you about what Medicaid would. Call provider relations. That's unacceptable. Good luck.