Confirming That Medicaid Check [Updated 12/04/13]

Please note the update below!

At the PMI practice management talk last week*, I ran through my usual RVU course which concludes with a walkthrough of the free RVU calculator.  It dawned on me that it has a new use in 2013 that I hadn't envisioned when I wrote it.

Calculating what your "Medicaid boost" check is supposed to be.

As many of you know, most states are participating in the ACA-driven program that will subsidize Medicaid, state or private, to pay at Medicare levels for certain procedures.  We have many clients who have already received these payments and they are substantial.

The problem is that when a check for $5,000 or $25,000 or even $80,000 (or more!) lands in your lap, you really don't have any idea if the number is right.  Sure, it's great to collect that extra money, but what if your $25,000 is supposed to be $30,000?   How would you know?  When you are on the phone with that frustrating private Medicaid payer, wouldn't it be nice to be able to tell them how much of a check you expect to see before it arrives?

Of course, there are practice management systems that will help you figure this out easily, but for those of you stuck without any RVU functionality, here's what to do:

  1. Head to the RVU Calculator page, download the calculator, load the RVUs from the Feds.  Set your location properly and your Medicare Multiplier to 100% (i.e., Medicare rates).
  2. For each Medicaid payer you participate with, enter in your unit volume for the code set that gets the boost (essentially all E&Ms and vaccine admins) and then what you were paid.  Specifically, enter your units in column J and your payments in column M.
  3. [New Step] I was reminded by Dr. Barden that the AAP slipped into the formula this little gem:
    In 2013 and 2014, state Medicaid programs must pay physicians with a specialty designation of family medicine, general internal medicine, or pediatric medicine for these codes at least at the Medicare rate in effect in CYs 2013 and 2014, or if higher the rate using the CY 2009 Medicare conversion factor and 2013 and 2014 RVUs.
    So, in cell B10, where there presently exists a gawdaful formula that should result in "$34.02" (the 2013 Medicare CF), just overwrite it with $36.07, the 2009 Medicare CF. For those scoring at home, that's an additional 5.7% increase!
  4. In Column R (and in row 14 in this case), add the simple formula:

    ...and you can see exactly how much you should expect for payment on that code.  The formula multiplies your units for each CPT code by the difference between the Medicare fee schedule and what you were paid.  Presto!

  5. Copy the formula into each of the rows for the CPT codes you recorded and then get a total for that column.  Wow, that's a big number.

How hard was that?  I have been telling practices that if they get a check for $50,000 and they expect $52,000, it's probably not worth the effort to track the money down.  But if you expect $52K and get $40K, that's another story.

* Why are these PMI events not fully packed?!  I don't get it.  Here's what one attendee had to tell me this week:

"I found the conference fascinating and extremely relevant to running my practice. On Monday, I revised our pricing, spoke to our staff about the 799.xx codes, calculated our Net Collection ratio, instituted the Transitional and Chronic Care Code...and that is only a fraction of my to-do list!

Without hyperbole, I suspect that by 10am Tuesday, I paid for my entry fee and by close of day, paid off my airplane fare and hotel costs. I will be recommending this seminar to anyone who will listen."

How can you beat that?!