Alejandro Badia, MD
Healthcare Disruptor & Author
Billing and Collections Manager
at Badia Hand To Shoulder Center
Fixing Healthcare…From The Trenches Episode 10
Flyer (Episode 10)
Dr. Badia here for this week’s edition of Fixing Healthcare From the Trenches. I have the utmost pleasure to actually invite a guest today who is from the trenches, I mean the real trenches of healthcare and the financial part who will explain to you the challenges that physicians and, I’m going to put it right out there. That’s not so much me, and I’ll explain why. The vast majority of my colleagues here and even abroad anywhere where there’s either government control of healthcare or private insurance, the challenges we face. Tina Rodriguez has been in healthcare in billing and collections for over a quarter century. She’s been with us at Badia Hand to Shoulder Center for 14 years. She also helps consult with billing issues in OrthoNOW, which is a platform that will soon be going national and international. So she’s worked for a variety of you know, providers and she’ll be able to give us some insight as to what the problems are. So Tina, welcome, welcome to the show.
Tina Rodriguez (01:07):
Thank you. Thank you for having me on a different aspect.
Tina Rodriguez (01:45):
So one of the major problems is, first of all, getting the patient here initially. On time to the proper provider. Get it done one time, the correct way, the correct time, and get them in to be treated
Right, not multiple steps, right?
Yep. And that was the goal of OrthoNOW
Tina Rodriguez (02:09):
A lot of the things that I face is when we’re calling the insurance and we’re asking the insurance, you know, we’re calling for status, we’re calling for, you know, have you received the claim? Whatever the case may be. We’re told that no, there’s no claim on file. We haven’t received the claim. I’ve even had EOBs in front of me where they said that they haven’t received the claim, and I have the EOB in front of me where they have paid.
So the EOB is this, this medical lingo, which even I would say most clinicians don’t even fully understand it, but that is a explanation of benefits. And many patients know, cause I know I get them at home, all right? From our current insurance, Humana, we’ve had here Blue Cross, we’ve had UnitedHealthcare, they’re all the same. They purposely make it so you don’t understand it. Okay. Except Tina understands it. That’s why I’m so glad she’s on our team. But it’s usually a three or four page document, which in my case at the end, basically many times states I didn’t get paid a red scent or a minimal amount. But the patients get it, and I think they don’t understand it. And what, what are the confusing parts of that? EOB for patients?
Tina Rodriguez (03:15):
Understanding how the explanation of benefits reads because on the corner, they get like a little code or a number, and then they have to go down to the bottom of the explanation of benefits to see what it is and by that explanation, the patient doesn’t understand what that means.
I don’t either
Tina Rodriguez (03:33):
Don’t understand what it means.
I ask Tina and Maria
Tina Rodriguez (03:36):
They dont understand their policy. Which is a big thing. When they obtain a policy, they’re not explained what the insurance doesn’t cover. They’re not explained very well. They’re not explained that they have an MNRP in their policy, which is a maximum non-network reimbursement plan
I see. I don’t even understand that
Tina Rodriguez (03:57):
You know, you bill, when you’re out of network, you bill the insurance and they tell the patients, we cover a hundred percent. Nothing is covered at a hundred percent. Nothing is covered at a hundred percent.
So let’s clarify that. I am what they call out of network and my gosh, if I could entice my colleagues out there listening to make that jump and go outta network why should Blue Cross or UnitedHealthcare determine what we get paid? They didn’t go to school and training on average, 12 to 14 years post-high school to do what we do. And, and yet, you know, look, look at what the was looking up yesterday. In fact, Walgreens, the chief executive, very astute lady made 58 million last year including the perks and I think the UnitedHealthcare guy is I mean, one of them is in, in excess of 150 million. So the point being is that when you’re in network, the insurance company can really decide what you’re worth and I don’t know of any other profession that way. Certainly my lawyer decides what they charge hourly, my accountant even my jet ski mechanic. This is where physicians need to really stand together. So what is the difference with in network and out network
Tina Rodriguez (05:18):
Well, in network, you have to go to a provider that is within their network. You don’t have the flexibility and the, and the want to go to a provider that you want to see, right? Because you’ve either been told, you’ve either been told that’s a good provider, he’s, you know, fantastic in orthopedics or in heart, or in whatever it may be. You have to go to where your insurance is telling you to go. That’s the difference between in-network and that network. Right? Out of network, you have the freedom of seeing whatever provider you choose to go see.
So that means for your primary care physician, if you’re very comfortable and they for some reason are not no longer in that network, you can’t see that person who’s been treating you for years or say you have a very I don’t know, your child has a very specific problem. I don’t know an eye issue and you need to see a pediatric ophthalmologist. I mean, you should, you should see the person you really want to see. Okay? I mean, we don’t, you know, we don’t mind spending money on certain luxuries, other things. And yet, when it comes to healthcare, I can tell you from our, our own office, right? When people call the second they hear, oh you don’t take my insurance. That’s the biggest phrase we hear. Well, it, that’s actually not true. What I, what I like to tell people is no, they, they don’t give it. It’s not that we don’t take it. Cause nobody in the right mind would take it to be paid. What, what are some examples of things that
Tina Rodriguez (06:38):
Oh, for example, if you take Medicare, Medicare pays $13 to $17 for an x-ray
My x-ray machine costs a quarter million dollar. I mean, everyone knows I tend to be very cutting edge. So I think it’s worth it, but it’s hard to make up $250,000 x-ray when you get paid $17 for an x-ray, right?
Tina Rodriguez (06:59):
So Medicare’s fee schedule is already very low and minimal so when you go in network and you sign a contract with that insurance carrier, you’re signing a contract that they’re gonna pay you on a percentage of Medicare rates
Usually less than Medicare
Tina Rodriguez (07:16):
So yes, they want to go less, right? 90% of Medicare, 95% of Medicare, which is very low.
Very low. I mean, because even Medicare, I mean, I think most clinicians, myself included still work with Medicare because we want to take care of the older sector of our society, which I’ll be joining in some years and the reality is that we, we realize that it doesn’t reimburse very well. But, you know, physicians that’s the problem is that the, the insurance companies often prey on our altruism. So it’s okay when we do that with our, our senior citizens. But for an insurance company now base their payment on what the federal government dictates for older patients. When you think about it, that’s an absurd concept. I thought that these companies were private. In fact, the problem is that they answer investors on Wall Street, and I think we saw all the problems with Wall Street some years ago and last week with banks. So we have our insurance companies, which, you know, tout the fact that they take care of us and we know they don’t. Who takes care of us is our physicians, our nurses, our technicians, our staff members who keep offices running and, and keep the lights on with reimbursements. So, so what are some of the other problems Tina?
Tina Rodriguez (08:29):
When you get an explanation of benefits and you don’t get paid properly, you have to do either a reconsideration or an appeal. You do that, it’s legwork. You have to call the insurance company.
You meaning, you and Maria, who we have. So we have two full-time excellent employees for one, one physician. So think about that. Think about my overhead
Tina Rodriguez (08:50):
It’s the tediousness that’s involved in all of that, right? It’s very tedious. You’re on the phone, you’re on hold for an hour. They come on, they help you with one or two patients, and they put you back in the queue, which means you have another hour now to hold to get another one or two patients done. It’s absurd. It’s absurd. It really is. It’s very absurd and then when you send that appeal, or you send that reconsideration… Another explanation of benefits comes back saying, oh, duplicate. It’s duplicate. No, it’s not duplicate. It’s a reconsideration or an appeal. So Maria has to get back on the phone, look in your system, it’s tedious, legwork on the same patient multiple times.
Now having somebody the workers at insurance companies actually kind of come out, you know, kind of sound like a Grisham novel where, you know, you know, the CEOs of these companies are gonna be chasing ’em down the highway and running ’em off the road. But they’ve admitted some of these people have admitted that, that they take these claims, you know, and I hate these words because to me, this represents my work for taking care of a patient and that these claims are a certain percentage of them Right. Are automatically denied. Yes. Because they figured not everyone has a great team like you and, and Maria to chase down something that we deserve to be paid. Right.
Tina Rodriguez (10:08):
You know, and all the seminars that I’ve been to, one of the biggest things is no claim on file.
Right? Right. That’s a common, and I hear you saying that
Tina Rodriguez (10:17):
Even the person who’s heading the seminar says, this is the biggest complaint, no claim on file. How do you have no claim on file when you have this have had the same address for 20 years? Right. And you don’t have the claims. Where are they going?
They go into, well, you know, where they’re at there with that black sock that when I do the wash, I always seem to lose one sock. because it goes, it goes into the fourth dimension.
Tina Rodriguez (11:01):
We can email them. We can, you know, whatever it takes to get you that claim to get it paid and get it paid properly, which is the biggest fight. We get duplicate, we get timely filing also because now they have to put a timely filing on there because after they say it’s been duplicated 10 times, well now they go to “oh you didn’t submit it on time”
So I don’t, I’m hoping those of you who are watching, so physicians watching you know this, but share this with, share these ideas or just share. It’s only a 15 minute podcast. Share this with the public. I mean, yes, I think most of the people are watching still are physicians. That’s not the goal of this podcast. Goal of this podcast is for the American public to understand why our healthcare system is now 20% of our GDP, our gross domestic product, one out of every $5 Okay. Goes to healthcare and the recent markers show that we are way behind the, the majority of the industrialized world in markers such as infant mortality, age, BMI a lot of markers that show health. It’s because the system. There’s great physicians, there’s great medicine here, but medicine is different than healthcare. Healthcare is how you access it and the care, and what Tina’s explaining is that it’s just the system can’t work like this. It can’t work like this. So what about the fact that, that a lot of times they’ll claim that I’m doing something experimental that’s another
Tina Rodriguez (12:42):
Yeah, that’s my big one.
Tina Rodriguez (12:44):
That’s my big one. That’s on a lot of your unlisted codes.
Because what the public needs to know is that when I do say a surgery, Let’s forget office visits. A surgery, there is a code associated. But as you imagine, not all surgery could be pigeonholed into certain numbers. Right. There are some things I do that are, are, are, are, are vastly different. And in fact, there’s some things I do that are a little more cutting edge and the billing people haven’t really caught up with it. But they’re not experimental. No.
Tina Rodriguez (13:14):
Well, worker’s comp is three to four years behind. Yeah.
Well so I’ll, I’ll give you one example. I’ve been doing arthroscopy at the base of the thumb. Anybody who knows me for almost 30 years. So it means I put a little scope for an arthritic joint and there is no code for that. So every time I do that, right, it’s, it’s tough to get reimbursed because it doesn’t matter what I do, how long I took it, the expertise, what, how, and how and how it positively affects a patient. All that matters. Now are these silly codes.
Tina Rodriguez (13:43):
And they want togo by a book.
Yeah. The the CPT book. Correct?
Tina Rodriguez (13:49):
I think someone is asking a question on how you can come see Dr. Badia as a patient if you’re not part of the network.
Tina Rodriguez (13:59):
The only way we can do that would be to have you come in as a self-pay patient. We can work with you as a self-pay patient. We can provide you with receipts, with statements, with anything that you need to try to submit on your own behalf to your insurance carrier and explain to them as the patient why you wanted to go see Dr. Badia and why you wanted to come to a world renowned specialist.
Because there’s a particular procedure perhaps that I do.
Tina Rodriguez (14:26):
That another provider will not do or does not.
Well, I think the ultimate answer to that question is that patients have to decide what their priorities are and I understand that you know, now the, the economy’s, you know, tougher. But I can tell you a few years ago when the economy was not so tough it was the same thing. The public is conditioned now to say, the first thing is, do you take my insurance? And the answer always is no. The reason being is that anybody who really looks and has somebody on staff like Tina and Maria, who, who does more of the collections, when they tell me how many things were not paid for at that point, 10 years ago, I decided to go outta network and I would be, you know, it would behoove anybody, any clinician who’s listening to look at that, yes, you will see less patients. And guess what? You will have a more pleasant experience with your patients. You’ll have time to ask them how the family is, what their, what their hobbies are, and really bond with the patient and spend more time with them. The reason patients complain nowadays about doctors being, you know, not spending time, is they simply cannot, when you’re getting paid for a follow-up visit, what in-network, a follow-up visit for
Tina Rodriguez (15:33):
$112- $97, depending on the carrier.
You think, you know, that you’re only, you know, let’s say you’re real fast and you’re seeing a patient every 15 minutes. All right, that’s 400 bucks an hour. But you have to think about the overhead. Tina’s one of eight employees, full-time employees. We have. And then, and then there’s malpractice insurance, which I still carry. That may change in the future. There’s the the overhead of the actual office, all the technology we have, the supplies. I mean, it goes on and on. So when you, when you look at what we’re paid, I mentioned my jet ski mechanic. My jet ski mechanic, his overhead are his tools and his van. Okay. That’s, that’s their overhead. And when you come to a physician, the overhead is really, is the expenses are astronomical. So when you think a hundred dollars, maybe, that’s not so bad. You know, it wouldn’t be that bad if I didn’t have that many expenses. Exactly. Right. But that 400 an hour is still about what my mechanic makes. So Tina, we would love to get some feedback from you on what couple initiatives. Typically I ask for three initiatives, but give us what you have and then I’m gonna go with my initiatives that could really vastly improve healthcare in the US.
Tina Rodriguez (16:52):
WellI mentioned it before. I think a big one is educating the patients. Yes. Educating them on how they can do what they need to do to see the correct provider. Educate them on their actual policy, their in-network, their out of network so that they understand their own policy, because a lot of times they don’t, they need to understand what their insurance covers, what their insurance doesn’t cover and I think getting them to the right physician on time makes a big difference in payments. You can avoid so much. You know, the insurance loves to have
Conservative treatment. When it’s something we know from the GetGo, it won’t work. Yeah. Number three. So I can.
Tina Rodriguez (17:34):
I think just knowing yourself as a patient and knowing what you want for your own self and for your family. Just get out there and help us spread the word. Spread
The word. So my three are actually in line with yours. My first one is right clinician at the right time. That saves a lot of money and obviously it minimizes mistakes. You know I’m an orthopedic surgeon, believe me, I haven’t examined the spine in 25 years. So you, you wanna see the right specialist. I believe in oversight, not authorization. Right. Because every time you have to authorize something, it’s another hurdle which delays care. And actually paradoxically increases cost. If that’s the one thing the insurance industry could listen to us, clinicians, for me it would be that and then the third one is public education, as you mentioned. Yes. What we’re doing here with the podcast, with the, he book I wrote, healthcare from the Trenches. You can find that on my website DrBadia.com, where the book website is simply HealthcarefromtheTrenches, where you can also get information about this podcast, see previous episodes and please subscribe, o YouTube. We’re on Apple podcast, we’re on Spotify. We’re on iHeart Media. So for those of you who like to listen to podcasts when you’re driving or when you’re at the, at the gym on the treadmill, these are only anywhere from 15 to 20 minutes. So any parting words, Tina?
Tina Rodriguez (18:59):
Come see us. Come see Dr. Badia. He’s world renowned. He’s a wonderful physician.
Well, that, that’s my mom’s plug. Come on that, that’s the
Tina Rodriguez (19:17):
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