From Kind Chang Plastic Surgery; the Department of Surgery, Division of Plastic and Reconstructive Surgery, University of California-San Francisco; the Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; the Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital; PRMA Plastic Surgery; and the Department of Plastic Surgery, University of Texas Southwestern Medical Center.
Plast Reconstr Surg. 2021 Jul 1;148(1):239-246. doi: 10.1097/PRS.0000000000008062.
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.
自《患者保护与平价医疗法案》签署成为法律以来，人们一直在推动摆脱按服务收费的支付模式。捆绑支付的兴起对整形外科医生的收入产生了巨大影响，尤其是私人执业的无薪外科医生。因此，医生现在必须尝试与保险公司优化合同报销协议（除外条款）。本文旨在解释协商除外条款背后的经济学原理，并为整形外科医生提供在这些谈判中使用的操作指南。
基于工作相关的相对价值单位、医疗保险报销、间接费用、医生工作量和预期收入，作者提出了一种方法，使外科医生能够评估他们为各种手术获得的报销金额。然后，作者回顾了影响是否可以进行除外条款的因素。最后，作者考虑了与保险公司谈判的相关细微差别。
以组织扩张器插入术（CPT 19357）为例，作者审查了确定是否应进行除外条款的数学、所需的思维过程和必要步骤。还确定了与保险公司进行谈判的策略。所提出的方法可用于潜在地协商任何符合适当财务标准的重建手术的除外条款。
了解实践成本将使整形外科医生能够评估保险报销的真正价值，并确定是否值得追求除外条款。整形外科医生必须随时准备协商足够的报销除外条款。最终，通过使最佳质量的患者护理与保险公司的财务动机保持一致，整形外科医生有机会提高某些重建手术的报销水平。
