managed care related issues, credentialing, etc.

[dl2dp2]

Some of you on this board might have a better sense, so I figure I'd throw this one out there. It appears that it's feasible to be in-network and out-of-network at the same time. For example, in a private practice, people bill the patient directly and the patient gets out-of-network benefits by submitting a bill. However, in a moonlighting/full time job inpatient job scenario, you credential through your hospital's Tax ID, but you are on the panel for the insurance. You are billing the insurance, and you are getting paid as an in-network provider.

Clearly people do both at the same time. However, I'm not sure why this is not a loophole that people aren't exploiting more often or that insurance hasn't closed yet. For example, one could open a group practice that takes insurance, and then open another "private" practice that doesn't take insurance and self-refer when patient can't afford out-of-network care. I'm not sure really how this works. Does this not happen because in effect you are competing against yourself? Or maybe I'm just living in too wealthy an area for this to be relevant...that the people who even look for out-of-network care are not in the same demographic of people who look for in-network care...??? Secondly, insurance companies could track providers instead of practices, and say, you can't provide out-of-network care ANYWHERE if you decide to do in-network somewhere. I don't understand why this hasn't happened yet. Thirdly, what about Medicare? Can you opt out of Medicare in your private practice but bill Medicare in a hospital?

---

Members don't see this ad.

 

[trophyhusband]

Some of you on this board might have a better sense, so I figure I'd throw this one out there. It appears that it's feasible to be in-network and out-of-network at the same time. For example, in a private practice, people bill the patient directly and the patient gets out-of-network benefits by submitting a bill. However, in a moonlighting/full time job inpatient job scenario, you credential through your hospital's Tax ID, but you are on the panel for the insurance. You are billing the insurance, and you are getting paid as an in-network provider.

Clearly people do both at the same time. However, I'm not sure why this is not a loophole that people aren't exploiting more often or that insurance hasn't closed yet. For example, one could open a group practice that takes insurance, and then open another "private" practice that doesn't take insurance and self-refer when patient can't afford out-of-network care. I'm not sure really how this works. Does this not happen because in effect you are competing against yourself? Or maybe I'm just living in too wealthy an area for this to be relevant...that the people who even look for out-of-network care are not in the same demographic of people who look for in-network care...??? Secondly, insurance companies could track providers instead of practices, and say, you can't provide out-of-network care ANYWHERE if you decide to do in-network somewhere. I don't understand why this hasn't happened yet. Thirdly, what about Medicare? Can you opt out of Medicare in your private practice but bill Medicare in a hospital?

Managed care organizations generally contract with the facility and all providers of that facility can bill that insurer (or if you're in a state where hospitals can't employ physicians there is a group that holds the contract). Each individual physician does not have a contract with the HMO/ACO (whatever). If that physician wants to see those patients in their PP they will need to be paneled separately from the facility contract. Now this is generally, I'm sure there are facilities out there where each provider has their own contract but that seems like a lot of work for everyone involved.

Basically, paneled does not necessarily mean you individually are contracted with the insurer.

As far as Medicare you are either in or you are out. This is what makes moonlighting or working part-time while having a cash only practice a bit of a crapshoot. Generally the place you work for wants you to have an NPI and be able to bill Medicare whereas when you have a cash only practice you should really be an opt-out provider and make it clear to your patients that they cannot bill Medicare. I'm sure plenty of people get away without opting out but all you need is one of your cash pay Medicare patients to decide they're going to bill Medicare for you to be in hot water.

 

[dl2dp2]

As far as Medicare you are either in or you are out. This is what makes moonlighting or working part-time while having a cash only practice a bit of a crapshoot. Generally the place you work for wants you to have an NPI and be able to bill Medicare whereas when you have a cash only practice you should really be an opt-out provider and make it clear to your patients that they cannot bill Medicare. I'm sure plenty of people get away without opting out but all you need is one of your cash pay Medicare patients to decide they're going to bill Medicare for you to be in hot water.

So, if you are "forced" to credential via Medicare because you either work or moonlight at a hospital, and you try to bill your patients directly as an opt-out (or even do the NONPAR billing), you are in theory committing Medicare fraud?

What this means is basically I can't sign any of the paperwork at the receiving hospital to credential me for Medicare. So if I have Medicare patient I'm whatever status I decide to be in my PP. If I'm opt-out this can wreck hovac in their billing. I don't even know how they would handle it if I'm NONPAR. Oh wait, if I'm NONPAR I suppose I can choose to take assignment for all my hospital patients, but then the hospital loses 10% for all the patients I see.

OH HELLS I HATE INSURANCE.

 

[trophyhusband]

So, if you are "forced" to credential via Medicare because you either work or moonlight at a hospital, and you try to bill your patients directly as an opt-out (or even do the NONPAR billing), you are in theory committing Medicare fraud?

Only if the patient tries bill Medicare at a later date. You're basically relying on your patients to keep you from committing Medicare fraud... not ideal. This is why it's better to opt-out and make it explicit to your patients that you are not a Medicare provider and they cannot bill Medicare for your services.

What this means is basically I can't sign any of the paperwork at the receiving hospital to credential me for Medicare. So if I have Medicare patient I'm whatever status I decide to be in my PP. If I'm opt-out this can wreck hovac in their billing. I don't even know how they would handle it if I'm NONPAR. Oh wait, if I'm NONPAR I suppose I can choose to take assignment for all my hospital patients, but then the hospital loses 10% for all the patients I see.

OH HELLS I HATE INSURANCE.

Not really sure what you mean by NONPAR as that term doesn't really apply to traditional Medicare. You are either a Medicare provider or you opt-out. Now if you're referring to Medicare Advantage then you can be non-participating or out-of-network but for traditional Medicare you're either in or you're out.

Again, some people don't opt-out of Medicare and they try to weed out Medicare patients but that's not as easy as they think it is. Not all Medicare patients are elderly and even C&A Psychiatrists can end up with Medicare patients that they weren't aware were on Medicare.

 

[dl2dp2]

Not really sure what you mean by NONPAR as that term doesn't really apply to traditional Medicare. You are either a Medicare provider or you opt-out. Now if you're referring to Medicare Advantage then you can be non-participating or out-of-network but for traditional Medicare you're either in or you're out.

Check this out, I don't think you are right:
http://www.medicare.gov/your-medicare-costs/part-a-costs/assignment/costs-and-assignment.html

and this:
http://www.aafp.org/practice-management/regulatory/medicare.html

There are 3 options
Par, nonpar and opt-out (private contract)

I believe what you are saying is going on in the private practice world. However, I'm not sure how this works in practice, because in theory if you ever moonlight you'd bill Medicare for your services, which means, that, in essence, you are billing and not billing Medicare at the same time, which is Medicare fraud.

 

[trophyhusband]

Check this out, I don't think you are right:
http://www.medicare.gov/your-medicare-costs/part-a-costs/assignment/costs-and-assignment.html

and this:
http://www.aafp.org/practice-management/regulatory/medicare.html

There are 3 options
Par, nonpar and opt-out (private contract)

I believe what you are saying is going on in the private practice world. However, I'm not sure how this works in practice, because in theory if you ever moonlight you'd bill Medicare for your services, which means, that, in essence, you are billing and not billing Medicare at the same time, which is Medicare fraud.

Yeah, you're right. Non-Par looks like it's an option. I don't know anyone who does this and just from reading that it looks like a disaster waiting to happen. Even after reading that I'd still say that realistically you have two options in or out.

Like I said, I'm guessing for moonlighting most people are still in and then just hoping that their private patients don't bill Medicare. If they're aware of this issue at all.

 

[mgdsh]

You can simply state you don't accept Medicare patients at your cash practice. Problem solved.

While PAR physicians must accept assignment on all Medicare claims, however, Medicare participation agreements do not require physician practices to accept every Medicare patient who seeks treatment from them.

 

[trophyhusband]

You can simply state you don't accept Medicare patients at your cash practice. Problem solved.

Of course you can, but if the patient doesn't tell you that they are a Medicare beneficiary and you won't be performing insurance verification (because you're a cash pay practice of course) they can still come and see you and pay cash. If they one day decide to bill Medicare for your services you can't then say well they never told me they had Medicare. You're putting a lot of trust in your patients by doing this... and like I said this is an issue that can even pop up for C&A Psychiatrists or Adult Psychiatrists who don't see the elderly as there are children, adolescents, and middle aged folks who are eligible for Medicare (which is why Medicare Advantage plans can no longer call themselves Senior, Elder, Aged, etc unless they were grandfathered in). Now there are so few non-elderly Medicare beneficiaries it's not a significant risk it's still a risk none the less if you decide to not opt out.

 

[mgdsh]

I have my own cash practice and despite not taking insurance, I still ask my patients what sort of coverage they have so I can still help to plan for their care. Very few patients that have medicare have ever contacted my office. I'm talking about less than 5% of the contacts I receive.

 

[trophyhusband]

I have my own cash practice and despite not taking insurance, I still ask my patients what sort of coverage they have so I can still help to plan for their care. Very few patients that have medicare have ever contacted my office. I'm talking about less than 5% of the contacts I receive.

I understand what you're saying and you're probably fine. If you're ok with probably fine then you don't need to opt-out if you want to be absolutely fine you need to opt-out. That's basically all I'm saying. It all depends on your risk tolerance... my wife's risk tolerance is very low so if she decides to go cash-only she'll be opting-out.

 

[michaelrack]

Can you opt out of Medicare in your private practice but bill Medicare in a hospital?

The solution is to be a medicare provider. As far as your private practice, you would then not take any medicare patients, or only a few (if you have the billing software, etc necessary to bill medicare)