Cash practice without Medicare opt out

[nexus73]

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Per the title, if someone wanted to start a modest side practice and accept cash only, but could not opt out of medicare due to their primary job, is it possible to screen out medicare patients? Or what strategies can be used to avoid problems?

 

[VA Hopeful Dr]

Yes, you'd have to screen out Medicare patients (and probably Medicaid).

 

[clausewitz2]

Per the title, if someone wanted to start a modest side practice and accept cash only, but could not opt out of medicare due to their primary job, is it possible to screen out medicare patients? Or what strategies can be used to avoid problems?

Nobody with kidney disease or over 60. Done.

 

[clozareal]

This is a problem I've been experiencing too. I'm neither opting out nor signing up as a non-participating provider with Medicare. I'm asking them if they have Medicare, but being careful not to say anywhere on my private practice that I'm not accepting Medicare because I do in other settings.

If they do have Medicare, I refer them to those who accept it saying that I cannot take them at this time. I'm not having them sign any form or anything and I'm trusting they are being honest with me. It might cause me problems later on, but I haven't figured out how to see if they have Medicare or not yet.

Is there a website or somewhere I can check if a patient has Medicare? I've been recommended to call Medicare but I don't want to be spending lots of time on this.

 

[Sushirolls]

Ask what their insurance is and then check it yourself.
There are some people who believe their XYZ insurance is XYZ and not a medicare advantage plan...
You need to be the one to figure this out. If they don't provide their insurance, for you to review, then don't accept them in.

Private entities can cap their medicare and medicaid patients. Non-profits can't... but they do it all the time and this is why I am in favor of ending all health care entity non-profit status.

You also need to be aware that patients age into medicare. So your 62yo private insurance, flips into medicare. Are you going to drop them or just carry forward with them?

Your private practice truly can't bill medicare, until you log into the system and do all the paperwork to have your new location/LLC/Tax ID to be able to 'accept assignment'. Currently, your employment with a different business you have signed over your 'assignment' for their location/LLC/Tax ID. Need to be careful to not delete that when messing around with all the paperwork.

You might be able to log in to your local MAC (one of like 5 or 9) different entities that run medicare in a regional basis. When logged in there you can enter the demographics of the person to check. But its been some time since I've done it and if its a viable way to check, or if you need to be able to look up each XYZ medicare advantage website, which they won't let you in, if you aren't paneled with them...

I've also had patients who have had primary commercial insurance, bus simmering behind the scenes they also had Medicare... or even medicaid... and they don't tell you about it.

 

[VA Hopeful Dr]

Nobody with kidney disease or over 60. Done.

Just saw a 29 year old with Medicare

 

[Jules A]

The intake form I use was adapted from forms given to me by two psychiatrists who have boutique practices. We also work in a hospital and therefore we cannot opt out of Medicare. The office policies document has a paragraph that indicates this practice doesn’t accept patients with Medicare with a place for patient to initial.

 

[troutscout]

It's been disheartening to have intro calls with folks who I find out are on Medicare but willing and wanting to pay OOP for my services doing cash only private practice. I am still working on some weekends doing locums so can't opt out, but have started a waitlist for when I can stop doing my locums and opt out of medicare. I am very transparent with these folks and let them know the situation. I now have a question on my consultation request on my website where they have to check a box if they have Medicare or not, so I can let them know before we talk on the phone since it can be such a letdown on their end, and not a good use of time on my end.

 

[splik]

Remember, this only applies to Original Medicare. If the pt has Medicare Advantage (which 42% of medicare beneficiaries do), it is as if they don't have medicare at all, and you can charge them cash. Also some pts only have Medicare Part A (for inpatient), if they don't have part B, you can charge cash.

Some additional things you can do to protect yourself include:
1. get a copy of front and back of pt's primary (and secondary if they have one) insurance
2. do not give superbills to pts who don't provide this information. They can't submit bills to medicare if they don't have them
3. Have pts sign an agreement that they do not have original medicare, that they will notify you if this changes, that they will need to find another physician if they do, and that failure to report this is grounds for termination from the practice.
4. otherwise if pt is on SSDI, over 65, has ESRD or ALS you should assume they have original medicare until proven otherwise

 

[trophyhusband]

Remember, this only applies to Original Medicare. If the pt has Medicare Advantage (which 42% of medicare beneficiaries do), it is as if they don't have medicare at all, and you can charge them cash. Also some pts only have Medicare Part A (for inpatient), if they don't have part B, you can charge cash.

Some additional things you can do to protect yourself include:
1. get a copy of front and back of pt's primary (and secondary if they have one) insurance
2. do not give superbills to pts who don't provide this information. They can't submit bills to medicare if they don't have them
3. Have pts sign an agreement that they do not have original medicare, that they will notify you if this changes, that they will need to find another physician if they do, and that failure to report this is grounds for termination from the practice.
4. otherwise if pt is on SSDI, over 65, has ESRD or ALS you should assume they have original medicare until proven otherwise

On #2 they can still complain to their local CMS MAC that you didn't provide a superbill and CMS will still come after you for charging cash to an OM beneficiary. This will not save you and it might make matters worse because they could plausibly argue that the reason you're not providing a superbill is because you're not doing your due diligence as a participating provider. I wouldn't say the likelihood of an issue is high but if you have a patient pestering you for a superbill and you won't provide it because they won't provide this info I'd be leery.

 

[trophyhusband]

Well it would be a red flag if they were asking for one because why would they need one if it they were self pay? And how could they complain about a superbill because if they had Medicare you would submit the claim yourself if you were a participating provider. Of course this is not going to completely prevent problems but the above can help reduce the risk by helping you to identify problem patients and showing your due diligence (ie that you aren’t knowingly billing Medicare recipients out of pocket.)

I work with Medicare all day every day... they will not see this as you doing your due diligence. They almost literally expect you to be psychic even though it makes no sense. They're maddening at the top level and their MACs are even worse.

 

[PikminOC]

Nobody with kidney disease or over 60. Done.

You'd be surprised. Lots of younger people on medicare

 

[PikminOC]

Ask what their insurance is and then check it yourself.
There are some people who believe their XYZ insurance is XYZ and not a medicare advantage plan...
You need to be the one to figure this out. If they don't provide their insurance, for you to review, then don't accept them in.

Private entities can cap their medicare and medicaid patients. Non-profits can't... but they do it all the time and this is why I am in favor of ending all health care entity non-profit status.

You also need to be aware that patients age into medicare. So your 62yo private insurance, flips into medicare. Are you going to drop them or just carry forward with them?

Your private practice truly can't bill medicare, until you log into the system and do all the paperwork to have your new location/LLC/Tax ID to be able to 'accept assignment'. Currently, your employment with a different business you have signed over your 'assignment' for their location/LLC/Tax ID. Need to be careful to not delete that when messing around with all the paperwork.

You might be able to log in to your local MAC (one of like 5 or 9) different entities that run medicare in a regional basis. When logged in there you can enter the demographics of the person to check. But its been some time since I've done it and if its a viable way to check, or if you need to be able to look up each XYZ medicare advantage website, which they won't let you in, if you aren't paneled with them...

I've also had patients who have had primary commercial insurance, bus simmering behind the scenes they also had Medicare... or even medicaid... and they don't tell you about it.

Medicare will claw back the money you made though if the patient files with them

 

[PikminOC]

And if they have Medicare advantage I have seen that the billing has to go thru Medicare first. Not sure if this is others experiences

 

[trophyhusband]

And if they have Medicare advantage I have seen that the billing has to go thru Medicare first. Not sure if this is others experiences

That's what's known as Med Sup or Medi-Gap... it's a secondary policy that pays for the cost sharing of Original Medicare. Medicare Advantage always runs through the insurer as if the member doesn't have Medicare at all as Spilk said (outside of very rare instances where Medicare starts covering something brand new and they cover it for a couple of year before requiring the MA plans to cover it).