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idea for a community group for medicare recipients - but not medicare billable?

JeyRo

Full Member
Mar 26, 2012
850
42
61
  1. Psychologist
Hi

For those of you familiar with working with medicare beneficiaries - I have multiple years of doing behavior management training with nursing staff on dementia issues. I had an idea of marketing and offering a group to dementia caregivers in the community (who, by the numbers, would likely be over half Medicare beneficiaries or more) but bypassing Medicare entirely and offering it as a private pay group.

I would primarily be doing education and (yes) coaching with caregivers on dementia and behavior management. I wouldn't consider this psychotherapy in all honesty, although some group supportive counseling elements may come into play naturally as an outgrowth of group dynamics. That way I wouldn't run afoul of medicare fraud rules.

I'm sure I'll be posting this on the CMS website as well, but I wanted to know if anyone thought this seemed like a reasonable way to go.
 

PHD12

Full Member
Nov 21, 2012
934
6
0
  1. Psychologist
Would you add an individual coaching/therapy component as an adjunct to the group? Based on networking with people in private practice, it should not be difficult for you to get several private pay patients, especially since you don't need many patients if you work full-time and you live in a wealthyish location. Your position as a VA psychologist (and someone who trains/supervises graduate students) should add to your value and expertise in the private sector. I've seen people charge $80-100 per group in CA so you may be able to make $700-1000 per group (not including rent).

I've also heard from tech savvy people that you can rent office/group space per day so you don't have to commit to a lease. From what I know, these are called shared spaces and you can rent them out on the internet (I have not done this myself).

I'm confused about one thing. If you wanted to do part-time private practice and specialize in caregiving/behavior management, why would this violate medicare rules if you find people who are wealthy and willing to pay $160 per session?
 
Last edited:

JeyRo

Full Member
Mar 26, 2012
850
42
61
  1. Psychologist
I'm confused about one thing. If you wanted to do part-time private practice and specialize in caregiving/behavior management, why would this violate medicare rules if you find people who are wealthy and willing to pay $160 per session?


If you offer a service to a medicare beneficiary, and you and the recipient agree to do a private pay agreement, you can still be pursued by medicare for fraud unless you have specifically opted out of medicare for 2 years and followed their specific 'opt-out' rules.

[edit]

The exception to the above is if the service is NOT covered by medicare. Then you're fine. Which is what I think I'm proposing here.

I've since asked this of a group of geropsych. folks I work with and they have told me that in their opinion I wouldn't arouse the wrath of the Medicare gods.
 
Last edited:
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Therapist4Chnge

Neuropsych Ninja
Moderator Emeritus
10+ Year Member
Oct 7, 2006
21,922
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276
The Beach
  1. Psychologist
It is really tricky because the OP would be providing services to a current Medicare patient, but bypassing Medicare input & billing, I am sure others have figured out a way to make this work within the Medicare parameters, but I don't know enough to provide a decent answer.

Medicare billing is as fun as herding rabid manic cats during a thunderstorm.
 

Therapist4Chnge

Neuropsych Ninja
Moderator Emeritus
10+ Year Member
Oct 7, 2006
21,922
3,239
276
The Beach
  1. Psychologist
That's why I try to avoid having to deal with Medicare whenever I can. I did it for a full year and it was painful.

Unfortunately most people will agree with you. We have an excellent billing company (specializes in neuropsych billing), so they try and keep the hassle to a minimum. If/When I leave academic medicine, I'm opting out of every insurance panel and will only do cash pay. There are enough other ways to supplement income I'd rather do than deal with the headache of insurance. It is a necessary evil at the moment.
 
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