not enrolling in medicare/terminating enrollment

[swisschard]

Oh wise ones, your knowledge is requested,
I was trying to figure out options about medicare enrollment/billing. I understand there are multiple options: enrolled and opted out, enrolled and participating (par), and enrolled and nonparticipating (non-par). PAR physicians get paid directly from medicare after submitting a claim to them, and NON-PAR collect it from the patient. Opted out docs can do private contracts with medicare patients. PAR and NON-PAR docs have to submit claims to medicare, and there are some differences in how incentives affect payments, as well as amount that can be charged. All this I know.

However, what I'm wondering about is if a provider is not enrolled in medicare, does the doc need to submit a claim? Also can docs who are not enrolled in medicare partake in private contracts with patients?

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[dl2dp2]

Excellent question. I explored this myself a year and half ago. This is apparently a gray zone with CMS regulations. Technically, I think if you are not formally opted out, you are counted as non-par and cannot charge more than the limiting charge. In practice, people who don't have any contact with Medicare usually have their patient sign a contract stipulating that they won't seek reimbursement, and charge whatever they want. As long as the patient doesn't contact Medicare, there's no legal way for Medicare to even know you exist. However, this ends up being a problem on occasion because patients ends up submitting the claim anyway.

Due to this and various other concerns and ambiguities, I decided to formally opt out of Medicare. I think you should consider making a decision as opposed to deliberately leave it blank.

 

[finalpsychyear]

Excellent question. I explored this myself a year and half ago. This is apparently a gray zone with CMS regulations. Technically, I think if you are not formally opted out, you are counted as non-par and cannot charge more than the limiting charge. In practice, people who don't have any contact with Medicare usually have their patient sign a contract stipulating that they won't seek reimbursement, and charge whatever they want. As long as the patient doesn't contact Medicare, there's no legal way for Medicare to even know you exist. However, this ends up being a problem on occasion because patients ends up submitting the claim anyway.

Due to this and various other concerns and ambiguities, I decided to formally opt out of Medicare. I think you should consider making a decision as opposed to deliberately leave it blank.

I'm curious as to why a lot of providers do not accept medicare. Overall, I have heard payments are said to be reasonable. Maybe fearing the federeal gov't is a factor? ex: overbilling/underbilling penalties are more severe than say a regular private insurance company?

 

[dl2dp2]

I'm curious as to why a lot of providers do not accept medicare. Overall, I have heard payments are said to be reasonable. Maybe fearing the federeal gov't is a factor? ex: overbilling/underbilling penalties are more severe than say a regular private insurance company?

>50% of psychiatrists don't accept ANY insurance. Medicare is just an example of a general pattern. The reimbursement is way too low and the market rate is much higher. Patient can and will pay market rates for quality care.

 

[downwithDTB]

I'm curious as to why a lot of providers do not accept medicare. Overall, I have heard payments are said to be reasonable. Maybe fearing the federeal gov't is a factor? ex: overbilling/underbilling penalties are more severe than say a regular private insurance company?

Hypothetically speaking, if a particular payer is known to set the rate of payment for a particular service... and that payer has a relatively inelastic demand for the service... if enough service providers opt out of that providing services to that payer, it just might increase payment rates for the service across the board.

 

[swisschard]

The crux of the issue is work outside of private practice: for example, one cannot be opted-out when working with agencies who bill medicare for your services and collect that reimbursement to indirectly pay you. I'm in that particular situation, and so opting out is not an option for me unless I decide to quit those jobs, which is certainly something I've considered.

Medicare indeed reimburses less than the market rate. Some private insurances provide better reimbursement, but then there is the hassle of their attempts to avoid payment and the extra expense this incurs.

 

[dl2dp2]

The crux of the issue is work outside of private practice: for example, one cannot be opted-out when working with agencies who bill medicare for your services and collect that reimbursement to indirectly pay you. I'm in that particular situation, and so opting out is not an option for me unless I decide to quit those jobs, which is certainly something I've considered.

This is apparently not an issue. When you work for a facility, the facility credentials you, and bills Medicare on your behalf. There are a number of people I know who work for a facility and opted out of Medicare but it's clear that it doesn't matter when they bill Medicare for services (i.e. emergency room, inpatient weekend coverage, etc.)

Similarly, if you run a facility yourself, in theory as long as it's located at a different place, you get a NPI/Tax ID separately, you can choose to bill insurance at one facility and take cash at another--as long as you don't have a non-compete with the facility. You don't deal directly with the insurance company for credentialing, because facility reimbursement is in general separately negotiated with the insurance company directly.

A clearer way to say this is, let's say you are Doctor MD who's hired as an outpatient employee at facility A, and gets paid a fixed salary of 150k a year, and moonlights on weekend at an outpatient employee at facility B, and gets paid $150 per hour. Private insurances often reimburse facility A and facility B at different rates for the same 99213 and 90836 that you bill, because they are negotiated directly with the facility. However, other than RVU bonus (which you negotiate with the facility, NOT the insurance company), you don't even get a sense of what the rates are, and hence there's no stipulation that you personally are "in-network" as long as the facility is "in-network" and you work under their umbrella. Insurance companies do this because otherwise things get confusing, you'd have to sign in-network contracts at every single venue you work. They prefer to deal with one administrator instead of hundreds of different clinicians. Medicare in theory cannot do this and has the same fee schedule no matter where you are, and therefore if you opt out you get paid nothing. In practice, in my experience unless the facility depends heavily on Medicare revenue, they don't care. And those who depend heavily on Medicare revenue usually handle staff salary based on block grants, so they REALLY don't care. I had one experience where I moonlight and the credentialing office wants me to send things in, and I just never sent them in. The paperwork (without the Medicare credentialing package) went through the HR no problem and I was still hired and still got reimbursed same rates for my shifts. Who knows how much they lost by using me to bill Medicare, and who knows if these claims were denied by Medicare. To be honest, they were not that sophisticated in that their credentialing system wasn't hooked up to PECOS--they never asked for my Medicare number, for example. None of this is my problem and I'm sure their HR staff didn't care, and their billing dept would never pursue it--it'll all be part of their "overhead". I would suggest you do the same if some locum job gives you flack. You sign a contract with the locum agency, not Medicare. They'll yield because they are desperate.

 

[dl2dp2]

Hypothetically speaking, if a particular payer is known to set the rate of payment for a particular service... and that payer has a relatively inelastic demand for the service... if enough service providers opt out of that providing services to that payer, it just might increase payment rates for the service across the board.

Insurance companies don't care about private practitioners who don't collectively bargain--they are happy to stick the bill to the patient. What happens more frequently is large employers have employees complain to HR that they can't find providers who are in-network. Usually what happens is that the employer negotiates directly with the insurance company for a higher rate, then recruits in-house "employee mental health services" for their employees as a perk. This is fairly common. College student mental health in an example of this.

In smaller markets more common in the Midwest/South, where access is a big issue and smaller groups (as opposed to hospital systems) are still more common, senior partners of large insurance taking private practices can have a lot of leverage in negotiating with insurance companies, when their patient list is very large. They can and have asked patients to collectively complain to the insurance company for lack of access to local providers. This forces the insurance company to set local rates higher. However, existing data show that even then a large fraction of psychiatrists only take cash, often at a lower rate compared to insurance--that's a separate issue that has more to do with the nature of psychiatric work than anything else.

 

[F0nzie]

Sluox crushed this thread


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[birchswing]

>50% of psychiatrists don't accept ANY insurance. Medicare is just an example of a general pattern. The reimbursement is way too low and the market rate is much higher. Patient can and will pay market rates for quality care.

Must be regional. There is a shortage of psychiatrists where I live, so you would think there would be a greater opportunity for private pay. I just went through the board of medicine web-site surveying every psychiatrist in the counties within driving distance from me. I would estimate 80-85% work for a single state hospital (elderly psychiatric residential with no admissions open to the public) or various military bases, with the rest working outpatient care, and out of those remaining they mostly work for service boards, with some moonlighting nights in private practice taking medicaid/medicare (I tried one such who had a room full of patients in a waiting room at 9 pm at night that looked like a bus station--his follow-ups were 4 months out, making it impossible to see him). Very, very few work solely in private practice and those that do take insurance. There was one very briefly who did private pay but he moved on--not from lack of interest from what I can gather. He was military and was doing the private pay as a moonlighting gig and has moved elsewhere.

What psychiatrists are offering for insurance-covered visits is not enough (for me). My psychiatrist bills a 99215 for each visit and gets $59.95 for that (including my co-pay).

Having looked up what a 99215 is and knowing what happens in our appointments, I believe what she's doing is . . . (you can draw your own conclusion). On the other hand, $59.95 is very little compared to what she would get in a private pay setting or what a cardiologist gets for insurance-based visits. I guess she's trying to squeeze out what is literally just a few more dollars.

So, I don't really get it. It seems like the environment should be ripe for private pay, but it just doesn't exist here. I'm thinking of going back to a service board. It practically takes a lawyer to get in to see someone there. But the shortage of private practice doctors means there aren't many options.

I'm literally the opposite of someone that you describe as willing to pay market rates for quality care (not that I wouldn't if I could--and I've tried). I'm at a point of trying to go back to a place for the indigent because there are so few options otherwise.

 

[swisschard]

Sluox crushed this thread

Seriously--thanks!

I'm trying to figure this out for my several contract gigs; I think you nailed it for all of them except Kaiser perhaps. They've been pushing me to enroll in Medicare and Medi-Cal saying it's a condition of per-diem employment. Upon looking deeper into the paperwork this appears to reassign medicare benefits to them, which as I understand allows them to bill medicare on my behalf and for them to collect it. I've called the Kaiser credentially folks and they seem to tell me I cannot opt out of medicare because this will cause problems with them being able to bill for me, and a rep from Noridian, the west coast medicare admin contractor, echoes this: that you are either all opted out or not--ie, you cannot be opted out at one facility and bill medicare at another.

 

[trophyhusband]

This is apparently not an issue. When you work for a facility, the facility credentials you, and bills Medicare on your behalf. There are a number of people I know who work for a facility and opted out of Medicare but it's clear that it doesn't matter when they bill Medicare for services (i.e. emergency room, inpatient weekend coverage, etc.)

Similarly, if you run a facility yourself, in theory as long as it's located at a different place, you get a NPI/Tax ID separately, you can choose to bill insurance at one facility and take cash at another--as long as you don't have a non-compete with the facility. You don't deal directly with the insurance company for credentialing, because facility reimbursement is in general separately negotiated with the insurance company directly.

A clearer way to say this is, let's say you are Doctor MD who's hired as an outpatient employee at facility A, and gets paid a fixed salary of 150k a year, and moonlights on weekend at an outpatient employee at facility B, and gets paid $150 per hour. Private insurances often reimburse facility A and facility B at different rates for the same 99213 and 90836 that you bill, because they are negotiated directly with the facility. However, other than RVU bonus (which you negotiate with the facility, NOT the insurance company), you don't even get a sense of what the rates are, and hence there's no stipulation that you personally are "in-network" as long as the facility is "in-network" and you work under their umbrella. Insurance companies do this because otherwise things get confusing, you'd have to sign in-network contracts at every single venue you work. They prefer to deal with one administrator instead of hundreds of different clinicians. Medicare in theory cannot do this and has the same fee schedule no matter where you are, and therefore if you opt out you get paid nothing. In practice, in my experience unless the facility depends heavily on Medicare revenue, they don't care. And those who depend heavily on Medicare revenue usually handle staff salary based on block grants, so they REALLY don't care. I had one experience where I moonlight and the credentialing office wants me to send things in, and I just never sent them in. The paperwork (without the Medicare credentialing package) went through the HR no problem and I was still hired and still got reimbursed same rates for my shifts. Who knows how much they lost by using me to bill Medicare, and who knows if these claims were denied by Medicare. To be honest, they were not that sophisticated in that their credentialing system wasn't hooked up to PECOS--they never asked for my Medicare number, for example. None of this is my problem and I'm sure their HR staff didn't care, and their billing dept would never pursue it--it'll all be part of their "overhead". I would suggest you do the same if some locum job gives you flack. You sign a contract with the locum agency, not Medicare. They'll yield because they are desperate.

I'm pretty sure you're confounding two different types of billing here. There is billing for the facility fee and then billing for the professional fee. I don't believe you have to be opted in for the facility to bill their fee but you do have to be opted in for them to bill your professional fee if you've assigned them to bill for you. The second is the issue for the OP in his/her later post. Kaiser and the MAC are correct that for them to bill the professional fee he/she needs to be opted in. Some places might be willing to just accept the facility fee and eat not being able to bill the professional fee (or they might just not be savvy enough to realize that they're screwing themselves) but Kaiser is assuredly not one of those places.

Edit: Other factors apply as well. Will you be working inpatient or outpatient? Will the outpatient clinic be an HOPD or a non-HOPD (not that the hospital is likely to tell you one way or the other)?

 

[dl2dp2]

Seriously--thanks!

I'm trying to figure this out for my several contract gigs; I think you nailed it for all of them except Kaiser perhaps.

This is possible. You have a couple of options. You can escalate it with the medical director, and basically ask if there's any room for negotiation on that--i.e. not personally take any Medicare patients. I *bet* you the medical director would say FINE, and then call HR and deal with it. If not, you can either not take that job if you really want to opt out, or do whatever they want with Medicare.

The only real downside to not opting out of Medicare is that you can't take private practice Medicare patients and charge them more on the side. Given few Medicare patients end up coming to private practice anyway, I don't think it'll be a big loss. Plus your Kaiser job may have a non-compete, so you may not be able do PP for the time being anyway. You can always opt out later. When I started my practice I was nervous that I couldn't get enough patients, so I signed up as a NON-PAR provider. It turns out 1) I didn't need Medicare 2) billing Medicare is extremely complex, and 3) I got a referral for a high fee private Medicare patient ==> so I opted out.

The only type of practice where this would be a bigger issue is where it's a geriatrics/neuropsych focused practice.

 

[dl2dp2]

I'm pretty sure you're confounding two different types of billing here. There is billing for the facility fee and then billing for the professional fee. I don't believe you have to be opted in for the facility to bill their fee but you do have to be opted in for them to bill your professional fee if you've assigned them to bill for you. The second is the issue for the OP in his/her later post. Kaiser and the MAC are correct that for them to bill the professional fee he/she needs to be opted in. Some places might be willing to just accept the facility fee and eat not being able to bill the professional fee (or they might just not be savvy enough to realize that they're screwing themselves) but Kaiser is assuredly not one of those places.

Edit: Other factors apply as well. Will you be working inpatient or outpatient? Will the outpatient clinic be an HOPD or a non-HOPD (not that the hospital is likely to tell you one way or the other)?

Yeah you are right there's a LOT of nuance. However, my suspicion is that Medicare/Medicaid heavy facilities like the ER separately negotiates with CMS. I moonlight at these facilities and credentialing with these places was never an issue. Each year the moonlighting roster changes dramatically. There's no way the facility would allow that many claims be denied and I know for a FACT that lots of people opt out. My friend works for an inpatient unit, and he never got credentialed with Medicare (no Medicare number) directly even though obviously he sees lots of Medicare patients. In theory he would be NON-PAR, and all kinds of complex billing issue would result. In practice, he got credentialed with the HOSPITAL, which has a contract with Medicare that says if a Medicare patient shows up and gets treated by an attending who got credentialed here, we will get reimbursed by X.

What's even more complex is that for inpatient and ER, X is different depending on the hospital. This is called "bundled payment". This apparently happens even though supposedly CMS sets the standard rate across the country by CPT code. The hospital negotiates with the state Medicaid office for reimbursement with Medicaid patients and the CMS regional MAC for rates for specific indications, since when they do bundled payment, they pay based on indication (i.e. psychosis vs. COPD, X for a typical hospital admission), rather than individual CPT codes. So as you can see, this is all immaterial if a specific physician opts out of Medicare---it's essentially only an administrative barrier. Hospitals generally don't check and see if a particular attending has opted out on his own or not, and Medicare doesn't have access to that information. Lately the word on the street is that the government is refusing to negotiate very much now for bundling, especially with Medicaid, and hardball hospitals since the hospitals can't deny patients based on insurance except in the outpatient setting (i.e. EMTALA, GME funding). So what ends up happening is the hospital gets sneaky on indirectly refusing indigent patients. Like they prioritize direct admissions and incentivize the ER to reject admission for community patients for which they lose money.

Medicare is a huge mess---when I applied through PECOS it's a tedious 10 step process. Filing claims is also a mess. Their software is 10-15 years old. You can do things a lot easier if you do a contract with a biller, but then that's another layer of middle man taking a cut. Medicaid is an even bigger mess. Their own redeeming quality is that the people on the phone are always nice and is a real American. Unlike for commercial insurance, where the phone line is basically designed to not let you get a real person, and at best some call center in India. Nevertheless, I've NEVER EVER needed to get credentialed for a moonlighting gig where most of the patients are Medicaid. I'm pretty sure most of these clinics derive at most 20% of revenue based on physician's Medicaid billing--? maybe midlevel billings make up for it?, and the rest comes from state block grants.

 

[trophyhusband]

Yeah you are right there's a LOT of nuance. However, my suspicion is that Medicare/Medicaid heavy facilities like the ER separately negotiates with CMS. I moonlight at these facilities and credentialing with these places was never an issue. Each year the moonlighting roster changes dramatically. There's no way the facility would allow that many claims be denied and I know for a FACT that lots of people opt out. My friend works for an inpatient unit, and he never got credentialed with Medicare (no Medicare number) directly even though obviously he sees lots of Medicare patients. In theory he would be NON-PAR, and all kinds of complex billing issue would result. In practice, he got credentialed with the HOSPITAL, which has a contract with Medicare that says if a Medicare patient shows up and gets treated by an attending who got credentialed here, we will get reimbursed by X.

What's even more complex is that X is different depending on the hospital. This is called "bundled payment". This apparently happens even though supposedly CMS sets the standard rate across the country by CPT code. The hospital negotiates with the state Medicaid office for reimbursement with Medicaid patients and the CMS regional MAC for rates for specific indications, since when they do bundled payment, they pay based on indication (i.e. psychosis vs. COPD), rather than individual CPT codes. So as you can see, this is all immaterial if a specific physician opts out of Medicare---it's essentially only an administrative barrier.

Medicare is a huge mess---when I applied through PECOS it's a tedious 10 step process. Filing claims is also a mess. Their software is 10-15 years old. You can do things a lot easier if you do a contract with a biller, but then that's another layer of middle man taking a cut.

When you're referring to a bundled payment I'm guess what you mean is the DRG. You're probably correct that hospital gets paid for these whether you're opted in or not.

I don't know what state you live in but I'd be surprised if any of the hospitals negotiate anything with CMS or Medicaid they're usually take it or leave it propositions. In the states I've worked in there was absolutely no negotiation and these were big boy hospital systems who if anyone could negotiate it'd be them.

At any rate, I'd guess the OP was working on a position that has outpatient responsibilities for Kaiser and will have to be opt in no matter what as they'll have to bill the professional fee. Even if there wasn't outpatient responsibilities Kaiser may be one of those places that has to dot all the i's and cross all the t's. Having worked with them before I'd be surprised if they budged on anything.

 

[splik]

Plus your Kaiser job may have a non-compete, so you may not be able do PP for the time being anyway.

restrictive covenants are unlawful in the state of california (where most Kaiser jobs are) so presumably this does not apply

 

[Extralong]

This is super interesting.

I do have a question. Say for example that I join a private practice that takes medicare/medicaid, so I have to be credentialed with them. And they work Mon-Thursday and I want to fill my Fridays with private practice patients, cash only. Is that possible? Please correct me if I am wrong, but most of the discussion above was about facilities and big hospitals, from what I gather.

 

[splik]

This is super interesting.

I do have a question. Say for example that I join a private practice that takes medicare/medicaid, so I have to be credentialed with them. And they work Mon-Thursday and I want to fill my Fridays with private practice patients, cash only. Is that possible? Please correct me if I am wrong, but most of the discussion above was about facilities and big hospitals, from what I gather.

the answer is yes the same principles apply - you bill under their Tax ID and have that separate from your sole proprietorship/LLC which has a separate Tax ID as articulated above. This may become more difficult in the future as medicare is trying to have everyone be all in or all out, but that just means you don't accept those patients into your pp. i am not enrolled in medicare and thus far have been able to prescribe drugs to medicare patients, however I have gotten a few letters from pharmacies telling me I will need to enroll in order for Part D to pay for the prescriptions, but it hasn't caused a problem yet. and in general, clearly if a patient is on medicaid/medicare you may want to question whether they would be able to pay cash anyway. so as long as you don't accept patients with medicaid/medicare into your cash practice it shouldn't be an issue. more of an issue is whether you will have a non-compete from this private practice group. in my area however it isn't uncommon for patients on medicaid to see a cash only psychiatrist, which not infrequently leads to issues when they can no longer pay.... Some patients will try every trick in the book not to pay even though they have signed a contract saying they will pay cash

 

[trophyhusband]

the answer is yes the same principles apply - you bill under their Tax ID and have that separate from your sole proprietorship/LLC which has a separate Tax ID as articulated above. This may become more difficult in the future as medicare is trying to have everyone be all in or all out, but that just means you don't accept those patients into your pp. i am not enrolled in medicare and thus far have been able to prescribe drugs to medicare patients, however I have gotten a few letters from pharmacies telling me I will need to enroll in order for Part D to pay for the prescriptions, but it hasn't caused a problem yet. and in general, clearly if a patient is on medicaid/medicare you may want to question whether they would be able to pay cash anyway. so as long as you don't accept patients with medicaid/medicare into your cash practice it shouldn't be an issue. more of an issue is whether you will have a non-compete from this private practice group. in my area however it isn't uncommon for patients on medicaid to see a cash only psychiatrist, which not infrequently leads to issues when they can no longer pay.... Some patients will try every trick in the book not to pay even though they have signed a contract saying they will pay cash

This is not correct is it? If you read the sample affidavits out there (http://www.aapsonline.org/index.php/article/opt_out_medicare/) you'll see wording like the following:

4. I hereby confirm that I will not receive any direct or indirect Medicare payment for Medicare Part B items or services that I furnish to Medicare Beneficiaries with whom I have privately contracted, whether as an individual, an employee of an organization, a partner in a partnership, under a reassignment of benefits, or as payment for a service furnished to a Medicare Beneficiary under a Medicare+Choice plan, during the Opt-Out Period, except for items or services provided in an emergency or urgent care situation. I acknowledge that, during the Opt-Out Period, my services are not covered under Medicare Part B and that no Medicare Part B payment may be made to any entity for my services, directly or on a capitated basis, except for items or services provided in an emergency or urgent care situation.

This is not dependent on which Tax ID you're working under it's dependent on who the provider billing for the service is or at least that's what I've found while researching this topic.

Additional info (https://www.sanctionscreeningnow.com/opt-out_faq.html)

What happens if a physician or practitioner who opts out is a member of a group practice or otherwise reassigns his or her Medicare benefits to an organization?

• Where a physician or practitioner opts out and is a member of a group practice or otherwise reassigns his or her rights to Medicare payment to an organization, the organization may no longer bill Medicare or be paid by Medicare for the services that physician or practitioner furnishes to Medicare beneficiaries. However, if the physician or practitioner continues to grant the organization with the right to bill and be paid for the services he or she furnishes to patients, the organization may bill and be paid by the beneficiary for the services that are provided under the private contract.
• The decision of a physician or practitioner to opt out of Medicare does not affect the ability of the group practice or organization to bill Medicare for t he services of physicians and practitioners who have not opted out of Medicare.

If someone has other info please let me know but base on the research I've done for the wife it's not possible to be opted out for only your PP and be able to have others (clincs , other PP's, Locums, or even those receiving block grants) bill for your services to Medicare. Now those orgs might not know it but if they are ever audited by Medicare they'll have to pay everything back and I wonder if they'd be able to come after you for the recouped amount (I guess it would depend on the contract).

Edit: @sluox I think I figured out why people can be opted out and still work in the ER:

"Install procedures to ensure that your office never files a Medicare claim, and never provides information to a patient that enables him to file a Medicare claim. The two exceptions - for emergency or urgent care and for covered services that Medicare would deem unnecessary - should be used with caution."

 

[dl2dp2]

... I'd be surprised if any of the hospitals negotiate anything with CMS or Medicaid they're usually take it or leave it propositions. In the states I've worked in there was absolutely no negotiation... for Kaiser and will have to be opt in no matter what as they'll have to bill the professional fee.

You are 100% right on both. Still, taking or leaving itself is a negotiation, because there are additional issues such as keep opening specific services that are predominantly Medicaid vs. not. All I'm saying is though if OP is determined to stay opted out, he can always ask that question. Also, I wonder if there are some kind of hidden backdoor to circumvent the 2 year opt out time limit. The idea is here is that once you opt out, you'd be ineligible for any employment at a Kaiser like facility for 2 years, but I wonder if Kaiser can help you apply for a waiver through some argument that there is an "unmet need". My experience has been that there are always backdoors like that.

This is super interesting.

I disagree. I hate trying to figure out this stuff . Everything is a negotiation and arbitrary. But our system is such that if you want to make more money you need to figure out the system.

If someone has other info please let me know but base on the research I've done for the wife it's not possible to be opted out for only your PP and be able to have others (clincs , other PP's, Locums, or even those receiving block grants) bill for your services to Medicare. Now those orgs might not know it but if they are ever audited by Medicare they'll have to pay everything back and I wonder if they'd be able to come after you for the recouped amount (I guess it would depend on the contract).

You are also 100% right. However I'm giving you the real world scenario, not what is "supposed" to be done. I'm fairly certain that this [opted out or non credentialed clinician bill insurance through internal credentialing] happens all the time, and Medicare does not audit this often enough to make this a problem. Medicare has bigger fish to fry with their audits, like over utilization of expensive procedures and biologics, so this particular loophole won't be closed any time soon, IMHO. While I think the emergency room exception might also be legally true, in practice I suspect nobody checks anything against anything... Lol I have NEVER heard of physicians being pursed for unpaid claims in a staffed facility position, especially locum, because a lot of times unpaid claims have nothing to do with what the physician does or doesn't do. If facility starts to set that precedence, nobody would work for them.

 

[trophyhusband]

You are also 100% right. However I'm giving you the real world scenario, not what is "supposed" to be done. I'm fairly certain that this [opted out or non credentialed clinician bill insurance through internal credentialing] happens all the time, and Medicare does not audit this often enough to make this a problem. Medicare has bigger fish to fry with their audits, like over utilization of expensive procedures and biologics, so this particular loophole won't be closed any time soon, IMHO. While I think the emergency room exception might also be legally true, in practice I suspect nobody checks anything against anything... Lol I have NEVER heard of physicians being pursed for unpaid claims in a staffed facility position, especially locum, because a lot of times unpaid claims have nothing to do with what the physician does or doesn't do. If facility starts to set that precedence, nobody would work for them.

You're right that they have bigger fish to fry with audits but these are so easy to find they'll figure it out eventually... all they really need to do is compare NPIs on the paid claims data to NPIs on the opt out list. Kinda surprised they haven't figured it out already but once RAC auditors figure it out this is going on it's easy money for them. Anyway, I work in Medicare/Medicaid finance and compliance (though not on the billing side) so I'd super conservative about this stuff. I've seen issues go from no big deal to multi-million dollar recoupments in the blink of an eye with CMS. It wouldn't be multi-millions for any one doc or anything in these cases but it would be enough to be super annoying.

In regard to the bolded, I've never heard of it either. But you're way more confident that it wouldn't happen than I am. If it comes down to closing the doors or PO'ing a few locums/contractors/moonlighters I'm thinking the docs are going to be in for a surprise (again assuming the contract allows for it). But again I'm just super conservative when it comes to CMS. Also, anyone reading this keep in mind what we're talking about here is outpatient services. Inpatient (Part A) is paid through IPF PPS which as far as I can tell is not affected by opting out and there is an exception for ER and urgent services.

None of this would matter if my wife only wanted to do C&A in a theoretical cash only PP but she likes adult for some variety and she really likes working with ID and DD individuals (some of whom can be on Medicare). So it would be easier for her to work in another clinic that services adults/ID/DD but since she'd be opted out just in case some of her C&A patients are on Medicare it'd be a risk. Ah well.

 

[swisschard]

restrictive covenants are unlawful in the state of california (where most Kaiser jobs are) so presumably this does not apply

Accurate. Per diem kaiser docs are allowed to work other jobs.

This is possible. You have a couple of options. You can escalate it with the medical director, and basically ask if there's any room for negotiation on that--i.e. not personally take any Medicare patients. I *bet* you the medical director would say FINE, and then call HR and deal with it. If not, you can either not take that job if you really want to opt out, or do whatever they want with Medicare.

The only real downside to not opting out of Medicare is that you can't take private practice Medicare patients and charge them more on the side. Given few Medicare patients end up coming to private practice anyway, I don't think it'll be a big loss. Plus your Kaiser job may have a non-compete, so you may not be able do PP for the time being anyway. You can always opt out later. When I started my practice I was nervous that I couldn't get enough patients, so I signed up as a NON-PAR provider. It turns out 1) I didn't need Medicare 2) billing Medicare is extremely complex, and 3) I got a referral for a high fee private Medicare patient ==> so I opted out.

Good idea with asking the medical director--I may try that. I really hesitate to submit the medicare application--I don't want my name to show up on medicare provider lists and be inundated w/ referrals to the private practice I do not wish to take. Then again, enrolled medicare providers don't have to accept new patients with Medicare/caid, so as long as one is diligent about screening it's not a problem.