Prudential / PruCare Health Insurance - Physician Reimbursement Schedule

PRUDENTIAL/PRUCARE

PRUCARE NETWORK

Current rating for PRIMARY CARE PHYSICIAN REIMBURSEMENTS--> * F

Their payments for OFFICE VISITS are--> * LOUSY!

Their payments for LAB WORK are--> * NONE

---CURRENT RECOMMENDATION---

3/10/98 PRUDENTIAL IS ALMOST THE LOWEST PAYER FOR OFFICE VISIT FEES (please see 10/21/97 comment below). NOW THAT THEY HAVE ELIMINATED ALL PAYMENT FOR LAB WORK, THEY HAVE PLUMMETED TO THE BOTTOM OF OUR COMPARISON LIST (click).
PATIENTS, AND EMPLOYERS SHOULD AVOID THIS INSURANCE. DOCTORS ARE FOOLS IF THEY ACCEPT PRUCARE PATIENTS.

-

---COMMENTS---

4/25/98 PRUCARE just lowered their payment for Audiometry (Hearing Testing) from $21.74 to $17.46, a drop of 20%. Our standard practice model assumes that you do 230 of these a year, doctor; so PruCare just stole another $984 from you and added it to their own annual profits.
---------------

3/17/98 BEN DOVER QUITS PRUCARE! (click to see letter)
---------------

3/10/98
WE'VE BEEN WARNING YOU
THIS WAS COMING!

Ben Dover has been predicting since August of 1997 (see below) that Prudential/Prucare would eventually eliminate their fairly good payments for lab work. As we've said all along, Prucare is a rotten payer for Office Visits (lower than Medicare!); so the only thing that used to make the plan the least bit attractive was the small profit (click) that doctors were able to make on lab work which helped defray the enomous cost of running and staffing a busy medical office.

Now Prudential has not only eliminated the lab profit, but they're even declaring that doctors contracted with Prudential must eat the cost of all lab work (click) if they send it to any lab not contracted with Prudential! See their arrogant letter (click).

CONSIDER WHAT THIS MEANS TO YOUR BOTTOM LINE, DOCTOR:

Prudential has reduced its payment for a Complete Blood Count from $19.20 to 0. Our practice model assumes (click) that you order 1,150 of these tests a year; so Prudential just droppped the gross income of your office by another $22,080 and added that to their profits.

Prudential has reduced its payment for a Cholesterol test from $48.00 to 0. Our model assumes that you order 460 of these tests a year; so Prudential just droppped the gross income of your office by yet another $22,080.

Prudential has reduced its payment for a Chemistry Profile from $40.00 to 0. Our model assumes that you order 1,150 of these tests a year; so Prudential just droppped the gross income of your office by another $46,000.

Prudential has reduced its payment for a Pap Smear from $20.00 to 0. Our model assumes that you order 690 of these tests a year; so Prudential just droppped the gross income of your office by another $13,800 and added that to their profits.

The elimination of just these four tests would reduce your office's potential annual gross income by $103,960. According to our standard model, if your entire practice was exclusively Prucare patients, elimination of the lab profit plummets your takehome pay from a respectable figure to a net annual income of $9,395. Yes, that's a measly $9,393 takehome pay for the entire year! Check out the Insurance Comparison Table (click) and note that Prudential/Prucare now ranks at the bottom.

Ben Dover thinks that any doctor who's willing to continue taking care of Prudential patients at these absurd rates is just flat NUTS!

Remember, doctor, that many of your patients with Prudential insurance (many IBM employees) have high-quality indemnity insurance; but Prudential has been working the "Silent PPO Scam" (click) on you by illegally limiting your reimbursements on these patients to the absurdly low PRUCARE PPO/HMO rates.

If you resign from your Prucare contract, you will no longer be bound by the low PPO rates; and you can charge those patients with good indemnity insurance whatever you and the patient agree is a fair fee (CASH!). Then simply give the patient the HCFA form to file to obtain whatever Prudential happens to be paying that week. If the patient is upset because his reimbursement from Prudential is too low, that's now an issue between him and Prudential (as is should be), not between the doctor and Prudential.
.

3/10/98 Prudential/Prucare just reduced its payment for a Throat Culture from $18.40 to $15.56, a drop of 15%. Our model assumes that you do 1,150 of these tests a year, doctor; so Prudential just stole another $3,266 from your family and added it to their corporate profits
--------------------

3/10/98 Prudential/Prucare just lowered its payment for a Tetanus/Diphtheria Booster from $23 to $12, a drop of 48%. If was assume that you give one of these boosters a week, doctor, then Prudential just stole another $506 from you and added it to their profits.
--------------------

2/14/98 PRUCARE just reduced their payment for a Stool Guaiac test for blood from $13.60 to $12, a drop of 12%. Our model assumes that you do 690 of these a year, doctor; so Prucare just stole another $1,104 from your family and added it to their corporate profits this year.
--------------------

11/19/97 PRUCARE just slashed its payment for a Chem-28 Profile from $72 to $40, a drop of 44.4%. Since we assume you do 1,150 of these a year, Prucare has just increased its profits by another $36,800 (!)this year, right out of your pocket, doctor.
--------------------

11/19/97 PRUCARE just lowered its payment for a Complete Blood Count (CBC) from $24.80 to $19.20, a drop of 29%. We assume you do 1,150 of these a year; so Prudential just stole another $6,440 from you this year, doctor.
--------------------

11/15/97 PRUCARE has dropped its fee for a Pap Smear from $22.40 to $20.00, a decrease of 11%. We assume that you do 690 of these every year; so Prucare has just increased their profits by another $1,584.
--------------------

11/15/97 PURCARE just lowered its payment for a Urinalysis from $19.44 to $16.80, a drop of 14%. Since we assume you do 1,610 of these a year doctor, Prucare just stole another $4,250 from your family and added it to their corporate profits. (NOTE: This latest cut follows on the heels of a prior 10% decrease in the UA fee earlier this year.)
---------------------

10/21/97

Prucare's payments for the two Office Visit codes we always compare (99212 and 99215) are very low; however, two of their OV codes that happen not to be scored in our template (99213 and 99214) are even lower, so low that they are actually below Medicare levels!!

Our standardized ranking template gives significant weight to potential lab profits, and Prucare happens currently to be paying very well for those specific CPT lab codes in the template. However, we anticipate that Prucare will continue a steady whittling-down process on their lab fees; so this strong positive influence on their ranking is likely to evaporate at some point. Once Prucare cuts their lab fees, they will drop down to the very bottom of our rankings.

---------------------------

10/14/97 PRUCARE / PRUDENTIAL just dropped its payment for Flu Vaccine to $15.32. Sigh!
---------------------------

8/18/97 Prucare has always been a low-payer for Office Visits, but they used to pay pretty well for lab work which sort of balanced things out. Now they are starting to LOWER THEIR PAYMENTS FOR LAB, and I suspect they will eventually eliminate lab payments altogether as some of the other companies have. Without any lab profit, it makes no sense whatsoever to take on Prucare patients. At the same time, they LOWERED THE PAYMENTS FOR ECG's AND OTHER OFFICE PROCEDURES BY 10%, perhaps thinking no one would notice.

The old Prudential indemity plans were pretty good until recently. Now every Prudential plan is using the absurdly low Prucare reimbursement schedule.

Another important caveat about Prucare: Last year they made a lot of noise about requiring all participating physicians to submit insurance claims electronically, but they backed down because there was a lot of squawk. I think they're just biding their time until they make this move again. If you're not already set up for electronic claims submission; it will cost you many thousands of dollars to purchase the required computer equipment; and then you'll also have to pay (out of your own pocket) the fee for each claim charged by the computer billing service. Personally, I wouldn't consider setting this up just for Prucare; since they're going to be a real money-loser once they cut out lab work.

-----------

PLEASE BOOKMARK http://home.earthlink.net/~austintxmd and check often for updates

NET PHYSICIAN INCOME

PRUDENTIAL/PRUCARE

Prucare Network

If you saw patients only from this one company for a full year, this is what you would earn.

Maximum Number of Each Click to see ASSUMPTIONS on which these figures are based

You Could Perform Fee
They Pay Totals
For Year

___Service____
Per Year

Office Visits (99212) 4,140 27.14 $112,360

Physical Exams (99215) 690 92.85 $64,067 HOURLY

Total Possible Income from Office Visit Charges--> $176,426 $153.41 Income

Total OFFICE OVERHEAD (click)--> -$206,600 __-$179.65 Overhead

Net ANNUAL PHYSICIAN INCOME--> -$30,174 -$26.24 <-- Net HOURLY MD Income

Hourly Physician "Wage" (based on an 8-hour day)--> -$16.40

INSURANCE REIMBURSEMENT AMOUNTS
(including patient copay)

CPT Code Description 1995 Payment Current Payment CHANGE

99211 Office Visit, MInimal 15.12 15.12 Payment For
<-- 4 Office Visits

99212 Office Visit (10min.) 27.14 27.14 $108.56

99213 Office Visit (expanded) 38.45 33.19 -13.7%

99214 Office Visit (detailed) 59.31 54.31 -8.4% Payment For One
<-- Physical Exam

99215 Physical Exam (40min.) 92.85 92.85 $92.85

93000 Electrocardiogram 30.24 27.22 -10.0% -$15.71 <-- What the doctor loses every time he does a thorough physical exam. See "Disincentives to Good Care"

94010 Pulmonary Function 34.31 30.88 -10.0%

85025 Complete Blood Count 19.20 0 -100.0%

81000 Urinalysis 21.60 16.80 -22.2%

80061 Cholesterol/LDL/HDL 48.00 0 -100.0%

80019 Chem-28 Profile 40.00 0 -100.0%

88150 Pap Smear 20.00 0 -100.0%

---------

Reprinted from: http://home.earthlink.net/~austintxmd

Introduction It's Not Insurance Any More Greedy Insurance Exec Dedicated Doc Graphic

Introduction for Doctors PPO or HMO - Both are BAD GUYS

Doctors Are the GOOD GUYS "Disincentives" to Good Care

Doctors' Income Business is Business

The Effect on Doctors What Can Be Done?

Send E-MAIL to AustinTxMD Compare Insurance The Latest Bad News

PRUDENTIAL/PRUCARE
PRUCARE NETWORK
Current rating for PRIMARY CARE PHYSICIAN REIMBURSEMENTS-->		*	F
	Their payments for OFFICE VISITS are-->	*	LOUSY!
	Their payments for LAB WORK are-->	*	NONE
	---CURRENT RECOMMENDATION---
3/10/98 PRUDENTIAL IS ALMOST THE LOWEST PAYER FOR OFFICE VISIT FEES (please see 10/21/97 comment below). NOW THAT THEY HAVE ELIMINATED ALL PAYMENT FOR LAB WORK, THEY HAVE PLUMMETED TO THE BOTTOM OF OUR COMPARISON LIST (click). PATIENTS, AND EMPLOYERS SHOULD AVOID THIS INSURANCE. DOCTORS ARE FOOLS IF THEY ACCEPT PRUCARE PATIENTS.
	-
	---COMMENTS---
4/25/98	PRUCARE just lowered their payment for Audiometry (Hearing Testing) from $21.74 to $17.46, a drop of 20%. Our standard practice model assumes that you do 230 of these a year, doctor; so PruCare just stole another $984 from you and added it to their own annual profits. ---------------
3/17/98	BEN DOVER QUITS PRUCARE! (click to see letter) ---------------
3/10/98	WE'VE BEEN WARNING YOU THIS WAS COMING! Ben Dover has been predicting since August of 1997 (see below) that Prudential/Prucare would eventually eliminate their fairly good payments for lab work. As we've said all along, Prucare is a rotten payer for Office Visits (lower than Medicare!); so the only thing that used to make the plan the least bit attractive was the small profit (click) that doctors were able to make on lab work which helped defray the enomous cost of running and staffing a busy medical office. Now Prudential has not only eliminated the lab profit, but they're even declaring that doctors contracted with Prudential must eat the cost of all lab work (click) if they send it to any lab not contracted with Prudential! See their arrogant letter (click). CONSIDER WHAT THIS MEANS TO YOUR BOTTOM LINE, DOCTOR: Prudential has reduced its payment for a Complete Blood Count from $19.20 to 0. Our practice model assumes (click) that you order 1,150 of these tests a year; so Prudential just droppped the gross income of your office by another $22,080 and added that to their profits. Prudential has reduced its payment for a Cholesterol test from $48.00 to 0. Our model assumes that you order 460 of these tests a year; so Prudential just droppped the gross income of your office by yet another $22,080. Prudential has reduced its payment for a Chemistry Profile from $40.00 to 0. Our model assumes that you order 1,150 of these tests a year; so Prudential just droppped the gross income of your office by another $46,000. Prudential has reduced its payment for a Pap Smear from $20.00 to 0. Our model assumes that you order 690 of these tests a year; so Prudential just droppped the gross income of your office by another $13,800 and added that to their profits. The elimination of just these four tests would reduce your office's potential annual gross income by $103,960. According to our standard model, if your entire practice was exclusively Prucare patients, elimination of the lab profit plummets your takehome pay from a respectable figure to a net annual income of $9,395. Yes, that's a measly $9,393 takehome pay for the entire year! Check out the Insurance Comparison Table (click) and note that Prudential/Prucare now ranks at the bottom. Ben Dover thinks that any doctor who's willing to continue taking care of Prudential patients at these absurd rates is just flat NUTS! Remember, doctor, that many of your patients with Prudential insurance (many IBM employees) have high-quality indemnity insurance; but Prudential has been working the "Silent PPO Scam" (click) on you by illegally limiting your reimbursements on these patients to the absurdly low PRUCARE PPO/HMO rates. If you resign from your Prucare contract, you will no longer be bound by the low PPO rates; and you can charge those patients with good indemnity insurance whatever you and the patient agree is a fair fee (CASH!). Then simply give the patient the HCFA form to file to obtain whatever Prudential happens to be paying that week. If the patient is upset because his reimbursement from Prudential is too low, that's now an issue between him and Prudential (as is should be), not between the doctor and Prudential. .
3/10/98	Prudential/Prucare just reduced its payment for a Throat Culture from $18.40 to $15.56, a drop of 15%. Our model assumes that you do 1,150 of these tests a year, doctor; so Prudential just stole another $3,266 from your family and added it to their corporate profits --------------------
3/10/98	Prudential/Prucare just lowered its payment for a Tetanus/Diphtheria Booster from $23 to $12, a drop of 48%. If was assume that you give one of these boosters a week, doctor, then Prudential just stole another $506 from you and added it to their profits. --------------------
2/14/98	PRUCARE just reduced their payment for a Stool Guaiac test for blood from $13.60 to $12, a drop of 12%. Our model assumes that you do 690 of these a year, doctor; so Prucare just stole another $1,104 from your family and added it to their corporate profits this year. --------------------
11/19/97	PRUCARE just *slashed* its payment for a Chem-28 Profile from $72 to $40, a drop of 44.4%. Since we assume you do 1,150 of these a year, Prucare has just increased its profits by another $36,800 (!)this year, right out of your pocket, doctor. --------------------
11/19/97	PRUCARE just lowered its payment for a Complete Blood Count (CBC) from $24.80 to $19.20, a drop of 29%. We assume you do 1,150 of these a year; so Prudential just stole another $6,440 from you this year, doctor. --------------------
11/15/97	PRUCARE has dropped its fee for a Pap Smear from $22.40 to $20.00, a decrease of 11%. We assume that you do 690 of these every year; so Prucare has just increased their profits by another $1,584. --------------------
11/15/97	PURCARE just lowered its payment for a Urinalysis from $19.44 to $16.80, a drop of 14%. Since we assume you do 1,610 of these a year doctor, Prucare just stole another $4,250 from your family and added it to their corporate profits. (NOTE: This latest cut follows on the heels of a prior 10% decrease in the UA fee earlier this year.) ---------------------
10/21/97	Prucare's payments for the two Office Visit codes we always compare (99212 and 99215) are very low; however, two of their OV codes that happen not to be scored in our template (99213 and 99214) are even lower, so low that they are actually below Medicare levels!! Our standardized ranking template gives significant weight to potential lab profits, and Prucare happens currently to be paying very well for those specific CPT lab codes in the template. However, we anticipate that Prucare will continue a steady whittling-down process on their lab fees; so this strong positive influence on their ranking is likely to evaporate at some point. Once Prucare cuts their lab fees, they will drop down to the very bottom of our rankings. ---------------------------
10/14/97	PRUCARE / PRUDENTIAL just dropped its payment for Flu Vaccine to $15.32. Sigh! ---------------------------
8/18/97	Prucare has always been a low-payer for Office Visits, but they used to pay pretty well for lab work which sort of balanced things out. Now they are starting to LOWER THEIR PAYMENTS FOR LAB, and I suspect they will eventually eliminate lab payments altogether as some of the other companies have. Without any lab profit, it makes no sense whatsoever to take on Prucare patients. At the same time, they LOWERED THE PAYMENTS FOR ECG's AND OTHER OFFICE PROCEDURES BY 10%, perhaps thinking no one would notice. The old Prudential indemity plans were pretty good until recently. Now every Prudential plan is using the absurdly low Prucare reimbursement schedule. Another important caveat about Prucare: Last year they made a lot of noise about requiring all participating physicians to submit insurance claims electronically, but they backed down because there was a lot of squawk. I think they're just biding their time until they make this move again. If you're not already set up for electronic claims submission; it will cost you many thousands of dollars to purchase the required computer equipment; and then you'll also have to pay (out of your own pocket) the fee for each claim charged by the computer billing service. Personally, I wouldn't consider setting this up just for Prucare; since they're going to be a real money-loser once they cut out lab work.
	-----------
PLEASE BOOKMARK http://home.earthlink.net/~austintxmd and check often for updates

NET PHYSICIAN INCOME
PRUDENTIAL/PRUCARE
Prucare Network
If you saw patients only from this one company for a full year, this is what you would earn.

	Maximum Number of Each				Click to see ASSUMPTIONS on which these figures are based
	You Could Perform		Fee They Pay	Totals For Year
	___Service____	Per Year	Fee They Pay	Totals For Year
Office Visits (99212)		4,140	27.14	$112,360
Physical Exams (99215)		690	92.85	$64,067		HOURLY
Total Possible Income from Office Visit Charges-->				$176,426		$153.41	Income
Total OFFICE OVERHEAD (click)-->				-$206,600		__-$179.65	Overhead
Net ANNUAL PHYSICIAN INCOME-->				-$30,174		-$26.24	<-- Net HOURLY MD Income
							<-- Net HOURLY MD Income
Hourly Physician "Wage" (based on an 8-hour day)-->						-$16.40

INSURANCE REIMBURSEMENT AMOUNTS (including patient copay)
CPT Code	Description	1995 Payment	Current Payment	CHANGE
99211	Office Visit, MInimal	15.12	15.12			Payment For <-- 4 Office Visits
99212	Office Visit (10min.)	27.14	27.14		$108.56	Payment For <-- 4 Office Visits
99213	Office Visit (expanded)	38.45	33.19	-13.7%
99214	Office Visit (detailed)	59.31	54.31	-8.4%		Payment For One <-- Physical Exam
99215	Physical Exam (40min.)	92.85	92.85		$92.85	Payment For One <-- Physical Exam
93000	Electrocardiogram	30.24	27.22	-10.0%	-$15.71	<-- What the doctor loses every time he does a thorough physical exam. See "Disincentives to Good Care"
94010	Pulmonary Function	34.31	30.88	-10.0%
85025	Complete Blood Count	19.20	0	-100.0%
81000	Urinalysis	21.60	16.80	-22.2%
80061	Cholesterol/LDL/HDL	48.00	0	-100.0%
80019	Chem-28 Profile	40.00	0	-100.0%
88150	Pap Smear	20.00	0	-100.0%
---------
Reprinted from: http://home.earthlink.net/~austintxmd


Introduction	It's Not Insurance Any More
Introduction for Doctors	PPO or HMO - Both are BAD GUYS
Doctors Are the GOOD GUYS	"Disincentives" to Good Care
Doctors' Income	Business is Business
The Effect on Doctors	What Can Be Done?
	Send E-MAIL to AustinTxMD	Compare Insurance	The Latest Bad News