3 ms·

Trying to apply "first principles" approaches to something as complicated as medical billing and reimbursement is a fools' errand. As a quick example before I m

Trying to apply "first principles" approaches to something as complicated as medical billing and reimbursement is a fools' errand. As a quick example before I move onto more pressing things, you ask, "If your ED visit is billed the same whether you're seen by an MD or NP, how would an NP go about saving you money?" It'd be helpful to know that they aren't billed the same! From CMS: > When an emergency department E/M is shared between a physician and a PA or NP from the same group practice and the physician provides the substantive portion of the E/M encounter with the patient, then the service may be billed under either the physician's or the PA's or NP’s UPIN/PIN number. If the physician does not provide the substantive portion of the encounter even if the physician participated in the service by reviewing the patient’s medical record, then the service may only be billed under the PA's or NP’s UPIN/PIN. In this scenario payment will be made at 85 percent of the Medicare physician fee schedule.

oaktrout 4y ago
Please correct me if I'm wrong here: You save $45 on the professional services, but you still pay the same facility fee (~$1000), the CT scan still costs the same (~$5000), labs are still the same (~$110)... etc. So maybe you have saved ~1% seeing an NP, hence why I said "billed the same", although you are correct that they are not the exact same. Now imagine that a NP orders a CT scan that was unneeded 1% more often than a physician, at this point it costs more on average to see the NP.
- mikeyouse 4y ago
  Again - this is far too complex to "first principles" your way out of. You need to be clear who you're talking about when you talk about savings (savings to the patient?, to the private insurer?, to medicare/medicaid?,to the hospital?, to the taxpayer if it's a public health system?) and even still, it will vary massively given that much of our care is state-driven. Your figures e.g. for a CT scan are wildly wrong if you're talking about anything government-paid. The reimbursement for a differential chest CT to the facility is closer to $150 from the government (https://www.cms.gov/medicare/physician-fee-schedule/search?Y=0&T=0&HT=0&CT=3&H1=71250&M=5 https://www.cms.gov/medicare/physician-fee-schedule/search?Y...) but again, that varies depending on a million other things. So making some claim like the 15% savings from an NP reimbursement is only 1% of the total cost of a visit needs a heck of a lot more specificity than your gut feeling on what things might cost.
  - oaktrout 4y ago
    I care about savings to the patient and taxpayer if that's helpful. I just googled "average cost of emergency department CT scan", I agree that is not what Medicare would reimburse.

oaktrout 4y ago

Please correct me if I'm wrong here: You save $45 on the professional services, but you still pay the same facility fee (~$1000), the CT scan still costs the same (~$5000), labs are still the same (~$110)... etc. So maybe you have saved ~1% seeing an NP, hence why I said "billed the same", although you are correct that they are not the exact same. Now imagine that a NP orders a CT scan that was unneeded 1% more often than a physician, at this point it costs more on average to see the NP.

mikeyouse 4y ago
Again - this is far too complex to "first principles" your way out of. You need to be clear who you're talking about when you talk about savings (savings to the patient?, to the private insurer?, to medicare/medicaid?,to the hospital?, to the taxpayer if it's a public health system?) and even still, it will vary massively given that much of our care is state-driven. Your figures e.g. for a CT scan are wildly wrong if you're talking about anything government-paid. The reimbursement for a differential chest CT to the facility is closer to $150 from the government (https://www.cms.gov/medicare/physician-fee-schedule/search?Y=0&T=0&HT=0&CT=3&H1=71250&M=5 https://www.cms.gov/medicare/physician-fee-schedule/search?Y...) but again, that varies depending on a million other things. So making some claim like the 15% savings from an NP reimbursement is only 1% of the total cost of a visit needs a heck of a lot more specificity than your gut feeling on what things might cost.
- oaktrout 4y ago
  I care about savings to the patient and taxpayer if that's helpful. I just googled "average cost of emergency department CT scan", I agree that is not what Medicare would reimburse.