Care providers operate in an environment characterized by multiple payors \u2013 Medicare, Medicaid, and a host of private health plans. The prevalence of such multi-payer is reason enough for differences in rates at which care providers are reimbursed despite the clinical procedures more or less being the same. Adding to this heterogeneous payor-environment is the regional differences wherein a physician practicing in an urban state gets reimbursed more than its counterpart in a rural state.\u00a0 Are we simply to believe that these are irreversible factors, and physicians are left with no avenues but to accept what is offered?<\/p>\n
Certainly, multi-payor system and regional factors should never hold you from claiming what you really deserve. If you happen to be as good a care provider as your counterpart in a metropolis, you are entitled to be reimbursed on par with the best rates. This is where your negotiation skills come into the fore \u2013 convincing you\u2019re your payors as to why they should reimburse you at the rates given in the fee schedule, equivalent to the CPT codes, and to the maximum extent possible.<\/p>\n
The extent to which you can negotiate is often decided by your being in a particular network \u2013 HMO or PPO. If you are a HMO provider, your negotiation is limited to Medicare or Medicaid fee schedule.\u00a0 Medicare, being public plan, reimburses you at a rate which is comparatively less than a physician gets by being a provider in PPO.<\/p>\n
At best you can insist on getting reimbursed on par with what the admissible CPTs deserve.\u00a0 But, to insist on being paid at CPT-equated level, you will certainly need to back up with clinical and quality credentials \u2013 care excellence, EHR implementation, and compliant coding and billing practices.<\/p>\n