Billing and abandonment

[PikminOC]

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If I want to build up a cash practice only, why can't I bill like my lawyers and accts who bill in 6-10 minute increments? That includes phone calls, paperwork, etc.

It seems as though they have no abandonment resposibilities. If I fail to make payment my taxes don't get done.

How would abandoment work in this type of scenario? Let's say a patient doesn't have the $100 prior to a 20 min med check. What then?

Thanks in advance. I am sorting through many options.

 

[F0nzie]

If you do not accept insurance you can bill however you want. That's the beauty of not working for insurance companies. Create an "Office Policies" contract that specifies billing procedures. If you want to be savvy and raise your collection rate, require that all your patients schedule their appointments online and book an appointment with their credit card information (make sure it's a secure terminal). Alternatively you can have them sign to keep their credit card information on file to charge for no shows or unpaid fees.

 

[whopper]

Each state's termination requirements differ.

You can refuse to see a patient that refuses to pay, but then based on the local laws and ethics, you may still be required to do certain things. E.g. offer a referral.

In Ohio, where I'm at, the doctor is required to send a letter via certified mail and provide 1 month of meds to terminate a patient. Despite this, I've seen plenty of docs not do this and nothing happened to them because the patient didn't know the legal requirements on the part of the doctor. There are several scenarios that cause automatic termination such as discharging a patient if you're an inpatient or emergency service doctor.

Personally, I'd let a patient go maybe once or twice if they did not pay, saying they need to pay it back, unless circumstances were extraordinary.

 

[toothless rufus]

If you do not accept insurance you can bill however you want. That's the beauty of not working for insurance companies. Create an "Office Policies" contract that specifies billing procedures. If you want to be savvy and raise your collection rate, require that all your patients schedule their appointments online and book an appointment with their credit card information (make sure it's a secure terminal). Alternatively you can have them sign to keep their credit card information on file to charge for no shows or unpaid fees.

But if you accept insurance then even for cash pay you are bound by the terms of insurance in general or something? How does that work?

 

[F0nzie]

But if you accept insurance then even for cash pay you are bound by the terms of insurance in general or something? How does that work?

The patient has to be out-of-network if you want to charge cash. If the patient was in-network and you charged cash, that would be like getting free referrals. There is no free lunch.

 

[PikminOC]

So you are automatically out of network if you don't accept their insurance?

 

[medium rare]

Yes, you're considered an out-of-network provider unless you've signed a provider contract with an insurance company.

However, a word of caution about Medicare. You MUST formally opt-out of Medicare if you want to see Medicare patients and have them pay you privately. If you don't know if you have opted-out or not, then you haven't. You must submit a formal affidavit to CMS and have them approve in order to opt-out. This is good for a 2-year period and then you must re-opt-out or become a Medicare provider.

If you haven't opted-out and haven't applied to be a Medicare provider, then you are in "no-man's-land" and risk inadvertently committing Medicare fraud. If you have not become a Medicare provider or opted-out, then you cannot see Medicare patients under any circumstances even if the patient agrees to pay you privately and even if they agree to not file claims with Medicare - to do so is considered Medicare fraud and, if discovered, you will have to repay everything the patient has paid you as well as pay a fine. This could easily be in the thousands of dollars.

This recently happened to a colleague of mine and scared the s*#t out of me. So, when it comes to Medicare, know your status.

 

[sunlioness]

When I was solo, I had a devil of a time getting Medicare to pay me anything. I was all in with them, but all the claims came back with something wrong with them or more likely just disappeared into some sort of ether. I'm so glad I don't have to worry about that stuff anymore.

 

[toothless rufus]

Sounds like the best course is to opt out of medicare, and just avoid all their BS, which is Legion.

 

[PikminOC]

What if the patient does not tell you they have medicare?

 

[pike73]

Yes, you're considered an out-of-network provider unless you've signed a provider contract with an insurance company.

However, a word of caution about Medicare. You MUST formally opt-out of Medicare if you want to see Medicare patients and have them pay you privately. If you don't know if you have opted-out or not, then you haven't. You must submit a formal affidavit to CMS and have them approve in order to opt-out. This is good for a 2-year period and then you must re-opt-out or become a Medicare provider.

If you haven't opted-out and haven't applied to be a Medicare provider, then you are in "no-man's-land" and risk inadvertently committing Medicare fraud. If you have not become a Medicare provider or opted-out, then you cannot see Medicare patients under any circumstances even if the patient agrees to pay you privately and even if they agree to not file claims with Medicare - to do so is considered Medicare fraud and, if discovered, you will have to repay everything the patient has paid you as well as pay a fine. This could easily be in the thousands of dollars.

This recently happened to a colleague of mine and scared the s*#t out of me. So, when it comes to Medicare, know your status.

Dealing with Medicare seems difficult. While it make sense to opt-out my understanding that it would need to be for 2 years. Once you opt-out I would assume that you would be prevented from billing Medicare in any setting, so if you would get another job within the two year span and then decided to do inpatient work or independent contracting work and would need to bill Medicare you would be in a jam. Private practive psychiatrists doing cash-only payments could easily miss a Medicare patient that agreed to just pay and not mention his insurance status. What would one recommend if it was discovered that you had a cash paying Medicare patient and the provider had not opted in or out? Would one refund all payments to the patient then refer him to another provider? I also know that Medicare can fine a provider as mentioned in the post. It was mentioned that this could cost thousands of dollars. Is this the repayment and the fine combined or just the fine? Also the writer mentioned a colleague that this happended to- was this fine considered a sanction that could interfere with his license or credentialing?

 

[digitlnoize]

Sounds like the best course is to opt out of medicare, and just avoid all their BS, which is Legion.

File under: Reasons to go into Child.

What about Medicaid? Do you have to do the same opt-out BS?

 

[billypilgrim37]

File under: Reasons to go into Child.

👍

 

[F0nzie]

Yea parents will sell their possessions to get their children the help they need. They won't for themselves though.

 

[sunlioness]

It makes me sad that selling possessions to get help for children is necessary. I'd rather stick with Medicare. I have people now who make sure they pay me. 🙂

 

[medium rare]

What if the patient does not tell you they have medicare?

It doesn't matter to Medicare. You have to ask the patient if they are Medicare eligible. If they are and you've opted-out, you have to have the patient sign a form indicating they understand you've opted-out and that they cannot file a claim for reimbursement.

 

[medium rare]

Dealing with Medicare seems difficult. While it make sense to opt-out my understanding that it would need to be for 2 years. Once you opt-out I would assume that you would be prevented from billing Medicare in any setting, so if you would get another job within the two year span and then decided to do inpatient work or independent contracting work and would need to bill Medicare you would be in a jam. Private practive psychiatrists doing cash-only payments could easily miss a Medicare patient that agreed to just pay and not mention his insurance status. What would one recommend if it was discovered that you had a cash paying Medicare patient and the provider had not opted in or out? Would one refund all payments to the patient then refer him to another provider? I also know that Medicare can fine a provider as mentioned in the post. It was mentioned that this could cost thousands of dollars. Is this the repayment and the fine combined or just the fine? Also the writer mentioned a colleague that this happended to- was this fine considered a sanction that could interfere with his license or credentialing?

I don't know if it would interfere with credentialing but I do not believe it was reported to the licensing board. It could show up on a credentialing check though. Typically, as I understand it, the ramification is the repayment of fees and the fine. I don't know what the fines are monetarily speaking, but you do have to pay back everything the patient paid you plus the fine.

 

[Dapplegrey]

Two separate discussions:

From what I understand it differs state to state. In Texas you can charge ancillary fees all day long in increments outlined in the contract your patient signed prior to their first appointment. My contract states I can charge them for fees not reimbursed by insurance at a rate of $200.00 an hour, I bill in 15 minute increments. As a courtesy to my patients I usually do not charge for forms, phone calls, etc that take less than 10 minutes. Most forms I charge for deal with disability or work/school accommodations. I've never had a problem with them paying the fee. I've opted out of Medicare and Medicaid for such restrictions, you can't charge them for ancillary fees and/or no shows/late cancellations.

Abandonment is another issue. In my private practice it's outlined in my patient agreement that after 3 no shows I can terminate their care. I send them a "30 day letter" stating that if they don't contact my office within 30 days I may cancel their treatment. Then after 30+ days I send a certified letter to the address on file that I am terminating our professional relationship (and that their records are available, etc). I've never terminated a patient due to non-payment or delinquent accounts, I don't ever want that to be an issue (e.g. you abandoned a patient because of money). Lack of compliance and follow up are the only reasons outlined in my termination letter.

 

[PikminOC]

Are you allowed to bill for extra fees if the person has private insurance and you are in network? When you sign an insurance contract i thought you can't bill for extra services.

 

[Dapplegrey]

I'm sure deep within the packet of a contract with an insurance company it states such, but it's a common practice within the local psychiatric community.

Different circumstance: I had a colleague that was contracted with an insurance company but was only accepting new self pay patients. When the patient submitted their receipt for out of network reimbursement my colleague received a letter from the insurance company stating that since he was contracted with them as an in network provider he could not charge the patient an out of network self pay rate.

When you get Medicare and/or Medicaid involved it becomes a matter of state and federal government rules and regulations.

 

[twright]

Abandonment is another issue. In my private practice it's outlined in my patient agreement that after 3 no shows I can terminate their care. I send them a "30 day letter" stating that if they don't contact my office within 30 days I may cancel their treatment. Then after 30+ days I send a certified letter to the address on file that I am terminating our professional relationship (and that their records are available, etc). I've never terminated a patient due to non-payment or delinquent accounts, I don't ever want that to be an issue (e.g. you abandoned a patient because of money). Lack of compliance and follow up are the only reasons outlined in my termination letter.

Do you need to refer a patient to another provider and ensure that s/he has successfully followed through with the transfer of care (or at least ensure that s/he has an initial appointment scheduled with the new provider) before terminating? Or is it enough (legally) to effectively say, "our contract stipulates X and Y, and you violated X, see you later"?

In our residency program we routinely cared for people who got dumped by their outpatient providers upon admission to the hospital (i.e., "I can no longer provide the level of care this patient needs. Since you have now assumed responsibility for his care, I am terminating my treatment relationship with him"). I assumed this was because these providers had a hard time finding another provider to accept the transfer.

 

[Dapplegrey]

When starting private practice I adopted the policies and procedures of my resident clinic. Our residency clinic was ran by a forensic psychiatrist who was hyper vigilant about teaching CYA. Figured I couldn't go wrong with that. I literally took a new patient packet from the resident clinic, reworked it a little, and use it as my new patient forms, clinic contract, and policies/procedures.

 

[kitsens]

File under: Reasons to go into Child.

What about Medicaid? Do you have to do the same opt-out BS?

can you guys explain what you mean? why this is a reason to do child?

 

[billypilgrim37]

can you guys explain what you mean? why this is a reason to do child?

Most kids are not old people.

 

[digitlnoize]

Most kids are not old people.

And thus, don't need or qualify for Medicare.

 

[toothless rufus]

Most kids are not old people.

However, a few do slip through the cracks: progeria. (I almost felt bad writing that, but...must...go...for...joke...)

 

[kugel]

Each state's termination requirements differ.

You can refuse to see a patient that refuses to pay, but then based on the local laws and ethics, you may still be required to do certain things. E.g. offer a referral.

In Ohio, where I'm at, the doctor is required to send a letter via certified mail and provide 1 month of meds to terminate a patient. Despite this, I've seen plenty of docs not do this and nothing happened to them because the patient didn't know the legal requirements on the part of the doctor. There are several scenarios that cause automatic termination such as discharging a patient if you're an inpatient or emergency service doctor.

Personally, I'd let a patient go maybe once or twice if they did not pay, saying they need to pay it back, unless circumstances were extraordinary.

Whopper, where does one find that law? Is it in Professional Codes or penal code or something else? What constitutes a "referral?" Doesn't the other provider have to agree to see the patient? My understanding is that a list of other docs does Not constitute "referral."

 

[michaelrack]

Whopper, where does one find that law? Is it in Professional Codes or penal code or something else? What constitutes a "referral?" Doesn't the other provider have to agree to see the patient? My understanding is that a list of other docs does Not constitute "referral."

http://www.state.nj.us/lps/ca/bme/faq/physFAQ.htm#11

above is an example. going to the website for your state medical licensure board is a good place to start the search for the relevant laws/rules regarding termination in your state.

 

[kugel]

http://www.state.nj.us/lps/ca/bme/faq/physFAQ.htm#11

above is an example. going to the website for your state medical licensure board is a good place to start the search for the relevant laws/rules regarding termination in your state.

Thanks.
Having read that link, I notice that, if the patient requests, the physician is expected to assist the patient in finding a new provider. Also, don't forget you are responsibile for providing care during that time if the termination takes place under circumstances that might lead to serious health consequences for the patient.

Also, please notice this makes no mention of waiving these t requirements for physicians working in managed care, I.e. whether you work in private practice or in Kaiser or some other configuration, YOU are responsible for these things, not the insurance company.

 

[twright]

Whopper, where does one find that law? Is it in Professional Codes or penal code or something else? What constitutes a "referral?" Doesn't the other provider have to agree to see the patient? My understanding is that a list of other docs does Not constitute "referral."

I don't know the answer, but I would assume that handing a patient an insurance company's provider list does not constitute a "referral". Wouldn't the standard be the same as provisions that are typically made for inpatients after discharge? (e.g., we have to get in touch with a provider or a provider's representative, the referral must be accepted, an appointment must be on the books, and the patient has to have enough meds to last until the appointment)

 

[F0nzie]

And if nobody is accepting referrals for 6 months they can come live with me for free! I call it the backdoor to my all inclusive concierge practice.

 

[sunlioness]

However, a few do slip through the cracks: progeria. (I almost felt bad writing that, but...must...go...for...joke...)

Well, it is true that not everyone on Medicare is on it because they're over a certain age. Disabled people are often on it too. I'm not sure about disabled kids though since I don't see kids at all. Anyway, if you don't see old folks you won't run into it nearly as much, but you still could.