Carving Out Financial Success: The Power of Insurance Carve-Outs in a Private Plastic Surgery Practice.
Journal
Plastic and reconstructive surgery
ISSN: 1529-4242
Titre abrégé: Plast Reconstr Surg
Pays: United States
ID NLM: 1306050
Informations de publication
Date de publication:
01 Jul 2021
01 Jul 2021
Historique:
entrez:
28
6
2021
pubmed:
29
6
2021
medline:
18
9
2021
Statut:
ppublish
Résumé
Since the Patient Protection and Affordable Care Act was signed into law, there has been a push away from fee-for-service payment models. The rise of bundled payments has drastically impacted plastic surgeons' incomes, especially nonsalaried surgeons in private practice. As a result, physicians must now attempt to optimize contractual reimbursement agreements (carve-outs) with insurance providers. The aim of this article is to explain the economics behind negotiating carve-outs and to offer a how-to guide for plastic surgeons to use in such negotiations. Based on work relative value units, Medicare reimbursement, overhead expenses, physician workload, and desired income, the authors present an approach that allows surgeons to evaluate the reimbursement they receive for various procedures. The authors then review factors that influence whether a carve-out can be pursued. Finally, the authors consider relevant nuances of negotiating with insurance companies. Using tissue expander insertion (CPT 19357) as an example, the authors review the mathematics, thought process required, and necessary steps in determining whether a carve-out should be pursued. Strategies for negotiation with insurance companies were identified. The presented approach can be used to potentially negotiate a carve-out for any reconstructive procedure that meets appropriate financial criteria. Understanding practice costs will allow plastic surgeons to evaluate the true value of insurance reimbursements and determine whether a carve-out is worth pursuing. Plastic surgeons must be prepared to negotiate adequate reimbursement carve-outs whenever possible. Ultimately, by aligning the best quality patient care with insurance companies' financial motivations, plastic surgeons have the opportunity to improve reimbursement for some reconstructive procedures.
Sections du résumé
BACKGROUND
BACKGROUND
Since the Patient Protection and Affordable Care Act was signed into law, there has been a push away from fee-for-service payment models. The rise of bundled payments has drastically impacted plastic surgeons' incomes, especially nonsalaried surgeons in private practice. As a result, physicians must now attempt to optimize contractual reimbursement agreements (carve-outs) with insurance providers. The aim of this article is to explain the economics behind negotiating carve-outs and to offer a how-to guide for plastic surgeons to use in such negotiations.
METHODS
METHODS
Based on work relative value units, Medicare reimbursement, overhead expenses, physician workload, and desired income, the authors present an approach that allows surgeons to evaluate the reimbursement they receive for various procedures. The authors then review factors that influence whether a carve-out can be pursued. Finally, the authors consider relevant nuances of negotiating with insurance companies.
RESULTS
RESULTS
Using tissue expander insertion (CPT 19357) as an example, the authors review the mathematics, thought process required, and necessary steps in determining whether a carve-out should be pursued. Strategies for negotiation with insurance companies were identified. The presented approach can be used to potentially negotiate a carve-out for any reconstructive procedure that meets appropriate financial criteria.
CONCLUSIONS
CONCLUSIONS
Understanding practice costs will allow plastic surgeons to evaluate the true value of insurance reimbursements and determine whether a carve-out is worth pursuing. Plastic surgeons must be prepared to negotiate adequate reimbursement carve-outs whenever possible. Ultimately, by aligning the best quality patient care with insurance companies' financial motivations, plastic surgeons have the opportunity to improve reimbursement for some reconstructive procedures.
Identifiants
pubmed: 34181623
doi: 10.1097/PRS.0000000000008062
pii: 00006534-202107000-00040
doi:
Types de publication
Journal Article
Review
Langues
eng
Sous-ensembles de citation
IM
Pagination
239-246Informations de copyright
Copyright © 2021 by the American Society of Plastic Surgeons.
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