Being a doctor is difficult. You need to graduate from medical school and learn a ton of difficult scientific concepts. You need to stay up to date on the latest medical developments. You need to cater to sick, needy patients (and their family). Any you need to get paid.
Earning a living is not as simple for doctors as other professions. Sure doctors make a lot of money. But knowing how much they get paid for a particular service is complex.
I provide an overview of the physician reimbursement system here. That overview does not take into account all the payment modifiers in the Medicare’s physician reimbursement system. Consider the following payment modifiers:
- For many procedures, Medicare pays providers for the professional and technical component. The professional component is the physician’s work and expertise; the technical component provides reimbursement for equipment and supplemental staff needed to perform the procedure. If the procedure is billed globally, then the physician receives both components. If another entity performed the technical component, then the physician is only paid for the professional component. For instance, for lab tests, the lab may run the test (technical component) but the physician would be the one interpreting the test (professional component).
- If you assist in a surgery, you receive 16% of the fee the primary surgeon does.Under some circumstances, the individual skills of two surgeons are required to perform surgery on the same patient during the same operative session. If you are a co-surgeon (rather than an assistant at surgery), you receive 62.5% of the typical reimbursement for that surgery.
- If you perform a bilateral surgery–a surgery done on both sides of the body (e.g., right arm and left arm)–then you receive 150% of the payment you would have received from doing a unilateral surgery.
- When multiple procedures are performed through the same endoscope, payment will be made for the highest valued endoscopy (100% of the allowance) plus the difference between the next highest and the base endoscopy.
- If you perform multiple surgeries in the same day on the same patient, you do not get paid the same amount as if these were performed on multiple days. The highest valued procedure is paid 100% of the allowance. For the second through the fifth highest valued procedures, the physician receives 50% of the typical payment amount.
- If you are a physician assistant, nurse practitioner, or a registered dietitian or nutritionists; you receive 85% of the payment an MD would receive for performing the same service.
- If you are a clinical social worker, you receive 75% of the payment an MD would receive for performing the same service.
- If you are a certified nurse midwife, you receive 85% of the payment an MD would receive for performing the same service. If you are a midwife, you only receive 65%.
- Participating providers receive the full Medicare Part B allowed amount as payment in full for services and bill the beneficiary only for any coinsurance or deductible that may apply. Payment for nonparticipating physicians (i.e., those who have not signed a Participating Payment Agreement) is 5 percent below the Medicare Physician Fee Schedule amount, but these physicians are permitted to bill patients up to 15 percent in excess of the fee schedule amount.
If you don’t think Medicare is bureaucratic, just take a look at those rules.