Insurance Panels and part-time private practice

[Sanman]

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A question out there for those who may have navigated this more than me. I am in-network with a number of insurance providers and paneled with medicare as part of my day job. I was contemplating possibly starting up a private practice on the side (maybe 1-2 days a week), but wanted to be cash only if I decide to do this. From my understanding, as a paneled provider I would not be able to refuse to take insurance on the side. Is that actually true or is it one of those things that can be gotten around in some other way. My other option is to only provide non-covered services, but I was curious about what others have done.

 

[PsyDr]

You'll need a healthcare attorney.

Long story short: you form a clinic under an LLC , get an NPI for a the clinic, and then only bill as the LLC and never as a "person". Might work depending on your contracts.

Medicare is going to be a huge problem. It is a crazy system. Even providers who have never enrolled in Medicare have to opt out of being a medicare provider before seeing a patient with medicare. The requirements for opting out are extensive and have to be done every two years. I don't know if you can do this under a clinic NPI while maintaining a provider NPI. The non-covered services are not an exception. Billing cash for this could be considered fraud. Almost anything is fraud in Medicare. Even under billing.

 

[AcronymAllergy]

You'll need a healthcare attorney.

Long story short: you form a clinic under an LLC , get an NPI for a the clinic, and then only bill as the LLC and never as a "person". Might work depending on your contracts.

Medicare is going to be a huge problem. It is a crazy system. Even providers who have never enrolled in Medicare have to opt out of being a medicare provider before seeing a patient with medicare. The requirements for opting out are extensive and have to be done every two years. I don't know if you can do this under a clinic NPI while maintaining a provider NPI. The non-covered services are not an exception. Billing cash for this could be considered fraud. Almost anything is fraud in Medicare. Even under billing.

Wow. So if I, never having been paneled by any company or ever having worked in private practice, were to go out into the community and start seeing patients, I'd need to opt out of Medicare before doing so? That's...fun. But very good to know.

 

[PsyDr]

Yup. Some newly licensed psychologist with 0 history of any insurance panelling could naively get a cash payment from a patient with medicare and get in all sorts of BS legal problems.

It's even worse, when you start reading about how a private medical office can be considered public property in other federal laws.....

 

[ClinicalABA]

Yup. Some newly licensed psychologist with 0 history of any insurance panelling could naively get a cash payment from a patient with medicare and get in all sorts of BS legal problems.

It's even worse, when you start reading about how a private medical office can be considered public property in other federal laws.....

Are you able to/comfortable with providing some references to specific laws or policy statements pertaining to this. Not that I don't trust advice form a stranger on the internet...😉

 

[Sanman]

Thanks PSYDR for the informative response. Medicare is my largest concern as being a geropsychologist it is unavoidable in my day job. However, I have no interest taking on dealing with CMS compliance in a side practice. I currently only do some side work a consultant and speaker at times. However, I am trying to figure out how to monetize my expertise in a reasonable fashion as there is a need, but I want to do so without taking on significant overhead related to insurance processing.

 

[PsyDr]

Are you able to/comfortable with providing some references to specific laws or policy statements pertaining to this. Not that I don't trust advice form a stranger on the internet...😉

No way I would possibly take offense at any of that. I'm not an expert and don't approach a decent understanding of this stuff. I would google, "medicare opt- out provider letter" or similar phrases until you get tired of that hole. The SDN psychiatry forum has a few mentions of this. I know EdieB knows a few things about this also. Here's one from a basic search: http://www.aapsonline.org/index.php/article/opt_out_medicare/

Thanks PSYDR for the informative response. Medicare is my largest concern as being a geropsychologist it is unavoidable in my day job. However, I have no interest taking on dealing with CMS compliance in a side practice. I currently only do some side work a consultant and speaker at times. However, I am trying to figure out how to monetize my expertise in a reasonable fashion as there is a need, but I want to do so without taking on significant overhead related to insurance processing.

There's got to be a way to see medicare patients in one place and get cash in another, but I just don't know how that's accomplished. I am extremely cautious with CMS or any federal agency, and very much believe in consultation with attorneys, so you might want to take that into consideration along with my opinions.

 

[ClinicalABA]

No way I would possibly take offense at any of that. I'm not an expert and don't approach a decent understanding of this stuff. I would google, "medicare opt- out provider letter" or similar phrases until you get tired of that hole. The SDN psychiatry forum has a few mentions of this. I know EdieB knows a few things about this also. Here's one from a basic search: http://www.aapsonline.org/index.php/article/opt_out_medicare/

Thanks for the link and info. I need to do some research on this to see if it's a potential issue in my practice. It's not intuitive to think it'd be a problem, so nobody may have even considered the possible when establishing current protocols.

 

[Peacemaker36]

No way I would possibly take offense at any of that. I'm not an expert and don't approach a decent understanding of this stuff. I would google, "medicare opt- out provider letter" or similar phrases until you get tired of that hole. The SDN psychiatry forum has a few mentions of this. I know EdieB knows a few things about this also. Here's one from a basic search: http://www.aapsonline.org/index.php/article/opt_out_medicare/



There's got to be a way to see medicare patients in one place and get cash in another, but I just don't know how that's accomplished. I am extremely cautious with CMS or any federal agency, and very much believe in consultation with attorneys, so you might want to take that into consideration along with my opinions.

I have looked into this as I am required to be a Medicare provider for my day job. I have been told by several authoritative sources (including someone at APA) that there is no way to charge patients your fee if you are a Medicare provider. You're either in or you're out.

 

[AcronymAllergy]

It's almost like they're encouraging people not to take any Medicare patients and/or be a Medicare provider...

 

[PsyDr]

It's almost like they're encouraging people not to take any Medicare patients and/or be a Medicare provider...

The DEFAULT is that you are in Medicare, even if you never enrolled as a provider. You literally have to opt out of the system, even if you have never agreed to be a medicare provider. Even after you opt out, that's still considered to last only 2 years. You have to opt out again every 2 years.

 

[ClinicalABA]

Any idea if things are similar for Medicaid?

 

[PsyDr]

I don't know much of anything about medicaid other than they don't pay for neuropsych codes in my home state.

 

[ClinicalABA]

Yeah- Medicaid tends to have more state specific guidelines and regs. Thanks for all the info you've provided on this topic.

 

[IT514]

Yup. Some newly licensed psychologist with 0 history of any insurance panelling could naively get a cash payment from a patient with medicare and get in all sorts of BS legal problems.

It's even worse, when you start reading about how a private medical office can be considered public property in other federal laws.....

This happened to someone I know. I don't know all of the details. He ended up ok but it was a long, expensive process for him to fix it.

 

[Sendtrees]

I am in the situation of the OP. When insurance is billed under my name, the institution that employs me gets paid--I am never paid directly by these insurance companies. In private practice, I work under my own name and at a different address. The NPI is the PITA that causes confusion--one NPI per person. I would have to incorporate and pay $500/yr for that in order to get a second NPI. But I have found that by explaining the situation in a letter, my patients ARE able to get reimbursed for out of network if they see me in my private practice. I worry that at some point, this will stop working...but I suppose then, I'll just go ahead and swallow the $500 per year to form an LLC and get a new NPI.

 

[Sanman]

Sendtrees,

What do you do with medicare patients? I assume this only works for private insurers.