Carving Out Financial Success: The Power of Insurance Carve-Outs in a Private Plastic Surgery Practice

• Published in: Plastic and reconstructive surgery (1963) Vol. 148; no. 1; pp. 239 - 246
• Main Authors: Kind, Gabriel M., Davis, Matthew J., Abu-Ghname, Amjed, Ochoa, Oscar, Hoxworth, Ron, Winocour, Sebastian, Maricevich, Marco, Chrysopoulo, Minas
• Format: Journal Article
• Language: English
• Published: United States Lippincott Williams & Wilkins 01-07-2021
• Subjects: Fee-for-Service Plans - economics; Fee-for-Service Plans - legislation & jurisprudence; Fee-for-Service Plans - organization & administration; Health Care Costs; Humans; Patient Protection and Affordable Care Act - economics; Patient Protection and Affordable Care Act - legislation & jurisprudence; Private Practice - economics; Private Practice - legislation & jurisprudence; Private Practice - organization & administration; Surgeons - economics; Surgery, Plastic - economics; Surgery, Plastic - legislation & jurisprudence; Surgery, Plastic - organization & administration; United States; United States
• ISSN: 0032-1052; 1529-4242
• 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.