Why I don’t accept Medicaid
Before I even opened my practice, I dreamed about how to make osteopathy financially within reach of as many people as possible. I had multiple mentors strenuously discourage me from taking insurance because of their negative experiences with denials, prior authorizations, rejections, and the bureaucratic nightmare of managing it all. I settled on using a sliding scale fee structure. As time went on, my inability to see people with Medicaid has felt increasingly unaligned with my intentions for my practice. So at the beginning of 2025, I set a goal for myself to get credentialed with Medicaid within the year.
Problem 1: My sliding scale - It is illegal for a doctor to charge individuals less than what they’re charging insurance companies. There are two exceptions:
They can apply an across-the-board discount for self-pay patients with the justification that it’s a discount for timely payment
They can have a sliding scale for people making less than 200% of the federal poverty guidelines. The payment tiers must be based only on income and family size, and the provider must have on file each patient’s tax returns or pay stubs as proof of their financial need.
I decided to use the second model because I wanted to be able to continue providing care for my many patients who can’t afford my full fee but do not qualify for Medicaid (especially given massive cuts being made to the program that is stripping millions of people of their coverage, including over 300,000 in Pennsylvania alone).
There are some losses in adopting the income-based sliding scale. My current fee structure attempts to holistically factor in people’s access to resources. $31,000 a year (the current 200% of the federal poverty guidelines for a single person) looks radically different for different people: consider a non-disabled, voluntarily under-employed, college-educated person whose family pays their rent vs a disabled person with $1,000 a month in medical expenses who’s helping their recently-immigrated parents pay utility bills.
Another loss of adopting the Medicaid-mandated sliding scale is that my current scale is based on the honor system. Having to maintain proof of people’s incomes is an administrative burden to both myself and my patients and runs counter to my efforts to foster a sense of mutual trust.
Problem 2: My documentation - My current progress notes are designed to meet my clinical needs: shorthand my structural exam findings and remind me of details of a patient’s history that I might otherwise forget. Insurance companies use notes for a completely different reason: as proof that the billing codes used were justified (or not).
Goddess-forbid I was to get audited by Medicaid in the future, my notes would need to include how much time I spent on each part of the visit (history, exam, treatment, counseling, documentation, reviewing labs/imaging, etc) a description of exactly which techniques were used for which body regions, and an explanation of why each treatment was medically necessary in language that would make sense to your average MD. As someone who approaches the body as a unified whole, it makes total sense to me that I would examine and treat the entire body and not just the area of complaint. (As AT Still, the founder of osteopathy said “When you step on a cat’s tail, where does the sound come out.”) But justifying that to a system that reduces people down to their component parts and then sends them from one specialist to the next is a daunting prospect. I actually started asking chatbots to write up sample notes and explanations of medical necessity so I could begin to get a sense of how I could word those. All told, this would increase the amount of time I spend documenting by at least 10x.
Problem 3: Billing - Related to the challenges of documentation, making sure that all of my codes are accurate and adequately justified is a challenge. On top of that, having to submit bills, track their payment, and appeal rejections is an enormous administrative undertaking.
However, I felt that the end result of being able to provide care to more people would be worth the sacrifices. So I started the process. The initial roadblock in moving forward was trying to find administrative support for credentialing (the process of signing on with insurance companies) and billing, and legal support to help me ensure that my notes and bills were compliant with Medicaid standards. I tried for months to find anyone who would work with a practice as small as mine and was unsuccessful. I finally gave up and decided I’d just move the credentialing process forward myself and manage my own billing for a time while I continued to look for administrative and legal support.
Once I decided to move the process forward on my own, the first step was getting approved by the state as a Medicaid provider. It was tedious and doesn’t bear recounting, but I managed to get my application packet together and it was eventually approved. Success!
However, because the Medicaid plans in Pennsylvania are managed by private insurance companies, there was one final hurdle to jump: I needed to get credentialed with those insurance companies. I imagined this was just a matter of getting all my paperwork in order, so I assumed the worst was behind me. There are two main companies that cover southeastern Pennsylvania. After much effort, I found out that one of them doesn’t recognize OMM as a specialty. A major setback but not a deal breaker. I figured being able to serve half of my potential patients is better than none, so I forged on with the other company. After extensive back and forth submitting and resubmitting my documents, at the final step of the process, they declined my application.
The reasoning they gave was that they already “have an adequate number of providers in their network.” I can’t even begin to express how absurd of an assertion this is given the tiny number of OMM specialists in general and the marginal fraction of them that take insurance. Undaunted, I asked what the appeal process was. They responded that there isn’t one but that I could submit prior authorizations for every single visit with no guarantee of getting paid for any of them. This is the point at which I gave up. I can already see patients for free without completely upending my business model and massively increasing my administrative labor, thank you so very much.
So to people who have managed to hang on to their Medicaid, I extend my apologies. If you live in the Philadelphia area, the OMM clinic at PCOM continues to take Medicaid (except for Health Partners Plans.) They are not always accepting new patients, but it’s worth calling to check. I will continue to offer care with a sliding scale fee structure and to dream and fight for a world where people can get the care that they need without profit-driven companies standing in the way.
