Medicaid for the Plastic and Reconstructive Surgeon

Abstract

Summary: Medicaid is a complex federally and state funded health insurance program in the United States that insures an estimated 76 million individuals, approximately 20 percent of the U.S. population. Many physicians may not receive formal training or education to help understand the complexities of Medicaid. Plastic surgeons, residents, and advanced practice practitioners benefit from a basic understanding of Medicaid, eligibility requirements, reimbursement methods, and upcoming healthcare trends. Medicaid is implemented by states with certain federal guidelines. Eligibility varies from state to state (in many states it’s linked to the federal poverty level), and is based on financial and nonfinancial criteria. The passage of the Affordable Care Act in 2010 permitted states to increase the federal poverty level eligibility cutoff to expand coverage for low-income adults. The aim of this review is to provide a brief history of Medicaid, explain the basics of eligibility and changes invoked by the Affordable Care Act, and describe how federal insurance programs relate to plastic surgery, both at academic institutions and in community practice environments.

Plastic Surgeon Financial Compensation–Incentivization Models in Surgical Care Delivery: The Past, Present, and Future

“…A list of common plastic surgery procedures and their associated relative value units are shown in Table 1. 10,11 Relative value units are then converted into a monetary value using a "conversion factor" to a fee schedule expressed in dollars. Although relative value units have been highly criticized, they remain the most common measure of surgeon productivity in the United States.…”

Paging All Readers! Let Us Explore Plastic Surgery Focus: Special Topics

“…With Congress periodically weighing changes that impact plastic surgeons, a primer on each topic by Firouzbakht et al is a helpful guide. 20,21 Nearly half of plastic surgeons report that 10 to 30 percent of their practice is made up of patients covered by Medicare. Whether Medicare reimburses for plastic surgery procedures depends on the "medical necessity" of the procedure, and clinical criteria and required documentation are strict.…”

“…For a plastic surgeon, knowing procedure coverage criteria for the state in which one practices is essential to serve the growing subpopulation of patients. 21…”

The Impact of Policy Reform on Utilization of Popular Reconstructive Procedures

“…The state of Maryland serves as an interesting case study of reconstructive surgery utilization by underserved populations (Medicaid patients) 4 . While Maryland expanded Medicaid coverage under the Affordable Care Act (ACA) in 2014, it also implemented a statewide policy mandating global budgets for hospitals that same year through its All-Payer Model (APM) 5–7 . The APM was designed to limit healthcare spending by disincentivizing low-value care (ie, readmissions) 8 …”

“…4 While Maryland expanded Medicaid coverage under the Affordable Care Act (ACA) in 2014, it also implemented a statewide policy mandating global budgets for hospitals that same year through its All-Payer Model (APM). [5][6][7] The APM was designed to limit healthcare spending by disincentivizing low-value care (ie, readmissions). 8 Prior literature has demonstrated that the ACA broadened access to a variety of health services, including surgical procedures, for Medicaid beneficiaries.…”