Managing Your Practice

Are ObGyns getting “bumped” out of deserved Medicaid reimbursement?

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The Medicaid expansion covered approximately 7 million more women in 2014, but not all of them were able to find a doctor. Here’s why, and how federal recognition of ObGyns’ importance to their patients could mean payment relief for you.



With enactment of the Affordable Care Act (ACA) came a number of significant changes to federal and state Medicaid programs to increase ­access to care for low-income individuals. One landmark change, which became a state option after a ruling by the US Supreme Court, is the expansion of eligibility to all adults who have an income at or below 138% of the federal poverty line, which was $16,105 annually for an individual or $32,913 for a family of four in 2014.

Pregnancy is no longer a criterion for eligibility for low-income women in states with expanded Medicaid programs—a real game changer for millions of women in need of care.

As of this writing, 27 states, including the District of Columbia, have expanded their Medicaid program. Data from the Centers for Medicare and Medicaid Services (CMS) show that total enrollment in the Children’s Health Insurance Program (CHIP) and Medicaid increased by more than 4.8 million people (from 58.9 million to 63.7 million) between July 2013 and March 2014, in the 47 states reporting data for both periods. Nearly all of this growth occurred in Medicaid expansion states.1,2 More recent data show that 7.9 million more people were enrolled in Medicaid in July 2014 than in the previous year.3,4

Is Medicaid a losing proposition for ObGyns?
In many states, it costs ObGyns more than Medicaid pays to provide primary care to Medicaid patients. Nationally, providers receive 41% less in Medicaid reimbursement than they get with Medicare for primary care services.5 In 2012, the worst offender was Rhode Island’s Medicaid program, which paid physicians only 33% of the Medicare reimbursement rates for primary care.5

The rate of Medicaid reimbursement affects a physician’s willingness to accept new Medicaid patients. Only 50% of physicians are willing to accept new Medicaid patients, compared with 70% who are willing to accept new Medicare or privately insured patients. Twenty-three percent of female Medicaid beneficiaries report a problem finding a new doctor, compared with 7% of Medicare beneficiaries and 13% of privately insured women. The main reason: low Medicaid payment rates.6

In 2007, 38% of all ObGyns accepted Medicaid gynecology patients, and 44% accepted Medicaid obstetric patients, with Medicaid accounting for 18% of revenue for the average ObGyn practice. In its 2013 survey of members, ACOG found that while 63.2% accept all Medicare patients, only 44.4% accept all Medicaid gynecology patients, and 48.7% accept all Medicaid obstetric patients, up from 2007. The percentage of ObGyns who don’t see Medicaid gynecology or obstetric patients was 22.7% and 16.3%, respectively. Only 8.2% of ObGyns see no Medicare patients.7

According to a 2014 survey, 34% of physicians report an increase in Medicaid patients; 41% of those report an increase of 11% or more.3

Organizations and programs that consider ObGyns primary care providers

The American Medical Association – The AMA considers the ­ObGyn specialty one of four specialties that provide primary care.

Tricare – The health-care program for uniformed service members (active, Guard/Reserve, retired) and their families around the world designates ObGyns as among primary care case managers.

Community Health Teams – A grant program to support primary care practices and patient-centered medical homes includes ObGyns as primary care providers.

Medicaid – Thirty-four states and the District of Columbia define ObGyns as primary care providers.

Medicaid Health Homes – Authorized under federal law to coordinate care for Medicaid enrollees with chronic conditions, health home providers coordinate all primary care, acute, behavioral health, and long-term services and supports to treat the whole person. ObGyns are eligible home health providers.

Health Resources Services Administration – This agency ­delineates health professional shortage areas, providing bonuses for physicians serving in these areas. It includes ObGyns as one of four primary care specialties.

National Health Service Corps – This organization offers loan repayments and scholarships to primary care providers working in underserved communities and recognizes ObGyns as primary care physicians.

Teaching Health Center Graduate Medical Education – This program supports community-based primary care residency programs to increase the number of primary care residents and dentists trained in geographically isolated or economically or medically vulnerable

Congress addresses the discrepancy
The ACA Medicaid primary care “bump,” as it’s called, was designed to help ensure access to primary care for the huge new group of individuals covered by Medicaid. It raised Medicaid payment rates for primary care services to Medicare fee levels in 2013 and 2014, an overall average increase of 73% in Medicaid payment rates for Evaluation and Management (E/M) codes 99201–99499, and for vaccine ­administration codes 90461 and 90471–90474 (FIGURES 1–3).8

Next Article:

ObGyn Medicare and CPT coding changes that could affect your income in 2015

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