Medicare /medicaid pts and cash practice

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
L

liquidshadow22

Junior Member
15+ Year Member
Joined
Jun 23, 2006
Messages
509
Reaction score
255
Is it true that one must specifically opt out of Medicare / medicaid prior to charging a patient out of pocket for a cash private practice visit? Am I only allowed to charge the patient whatever their Medicare/medicaid fee schedule would allow?
Members don't see this ad.
 
liquidshadow22 said:
Is it true that one must specifically opt out of Medicare / medicaid prior to charging a patient out of pocket for a cash private practice visit? Am I only allowed to charge the patient whatever their Medicare/medicaid fee schedule would allow?
Click to expand...
I don't know about Medicare, but Medicaid is super state specific. Some states allow you to make agreements with Medicaid patients that you will not take Medicaid as reimbursement and that they are privately responsible for the payments and it's kosher for you to see them. Some do not allow you to take money from Medicaid patients at all even with an understanding. I've found it extremely confusing, and I've found most practitioners don't know the law--even when I've called the state I've gotten conflicting answers--even more complicated is when Mediciad is secondary.

One thing that is new is that as of 2014 if you are a non-Medicaid-provider and prescribe meds to a Medicaid patient, Medicaid will not cover the cost of the medication. I believe that is mandated at the federal level. States do have a work around where you can sign up as an ordering/prescribing/referring Medicaid provider, which makes it so you are invisible to the public as a Medicaid provider (because you really still are not a Medicaid provider) but it does allow prescriptions you write to be covered by Medicaid. Not sure how that works in states where you are not allowed to take payment from Medicaid patients for service. I don't know if they could track those prescriptions to then see that you are taking fee for service—that workaround may only be for states that allow you to see a Medicaid patient with an upfront agreement with the Medicaid patient.

Anyhow, if you find the answer, it will be specific to your state. I have providers who have completely different interpretations of the state law, and so even with as much research as I have done I don't have a clear answer for my state.
 
liquidshadow22 said:
Is it true that one must specifically opt out of Medicare / medicaid prior to charging a patient out of pocket for a cash private practice visit? Am I only allowed to charge the patient whatever their Medicare/medicaid fee schedule would allow?
Click to expand...

Medicaid is state specific.

Medicare - opt-out to charge cash (any rate you want). Otherwise you bill Medicare.
 
Members don't see this ad :)
If I have to moonlight at a hospital with Medicare pts, then I cannot opt out for private practice only, correct ?
 
liquidshadow22 said:
If I have to moonlight at a hospital with Medicare pts, then I cannot opt out for private practice only, correct ?
Click to expand...

Yep that’s my understanding for Medicare. You’re either in or you’re out.

For Medicaid, it can be state specific and I’d look at your state laws. In some states, if both the provider and patients sign an agreement stating that all services will be cash only and absolutely nothing will be billed to Medicaid, you can have Medicaid patients in a cash practice even if you’re a Medicaid provider. Varies state to state though.
 
But why does opting in or out matter? Just don’t accept patients with a particular insurance you don’t have to legally opt out just don’t schedule them..or take only a couple
 
oldiebutgoodie1211 said:
But why does opting in or out matter? Just don’t accept patients with a particular insurance you don’t have to legally opt out just don’t schedule them..or take only a couple
Click to expand...

I agree but Ive heard this becomes a pain in the ass because you end up listed as a Medicare/Medicaid “provider” so then end up turning away a bunch of people who call because you’re on the eligible provider list.
 
calvnandhobbs68 said:
I agree but Ive heard this becomes a pain in the ass because you end up listed as a Medicare/Medicaid “provider” so then end up turning away a bunch of people who call because you’re on the eligible provider list.
Click to expand...

I have turned away ~2-3 patients this year who had Medicare bc I participate in my main job but not in private practice. I make it clear online that I am all out of network in my private practice and screen all patients for insurance type prior to scheduling them for intake. I do not have anyone >55 in my private practice right now.

I have friends who have seen patients unknowingly with Medicare in cash private practice and had to return all that $ or risk committing Medicare fraud
 
oldiebutgoodie1211 said:
But why does opting in or out matter? Just don’t accept patients with a particular insurance you don’t have to legally opt out just don’t schedule them..or take only a couple
Click to expand...


um, because you want to charge them cash for your pp. You can only legally do it if you opt out. "taking a couple" is technically breaking the rule, I dont know how easily it would be enforced honestly but def not worth the risk for a few pts
 
liquidshadow22 said:
um, because you want to charge them cash for your pp. You can only legally do it if you opt out. "taking a couple" is technically breaking the rule, I dont know how easily it would be enforced honestly but def not worth the risk for a few pts
Click to expand...

Eh no you’re not required to have a certain number of any type of insurance patients on your panel. The lists online are constantly wrong with who is “accepting new patients” or not anyway. Practices in other specialities cap percentages of their total practice they have from a certain insurance all the time (ex. will try to keep no more than 25% medicaid patients...you’ll find this out when you try to schedule a new appt and a Medicaid new appt is like 3 months out but a BCBS new appt can be next week). All you’d have to say for the people who you outright decline is that you weren’t accepting new patients.

Insurance companies list physicians who aren’t in network anymore, retired or even dead all the time. The bigger pain is dealing with the inquiries but as the poster above said, this is less of an issue for some practices.
 
calvnandhobbs68 said:
Eh no you’re not required to have a certain number of any type of insurance patients on your panel. The lists online are constantly wrong with who is “accepting new patients” or not anyway. Practices in other specialities cap percentages of their total practice they have from a certain insurance all the time (ex. will try to keep no more than 25% medicaid patients...you’ll find this out when you try to schedule a new appt and a Medicaid new appt is like 3 months out but a BCBS new appt can be next week). All you’d have to say for the people who you outright decline is that you weren’t accepting new patients.

Insurance companies list physicians who aren’t in network anymore, retired or even dead all the time. The bigger pain is dealing with the inquiries but as the poster above said, this is less of an issue for some practices.
Click to expand...

I never said you are required to take any amount of medicare or medicaid patients for a private practice. I'm just saying if you want to see the patient and not accept their medicare, then you must opt out of medicare to charge them cash out of pocket. i.e. the patient has medicare but wants to see you for their care despite you not being in network with their govt insurance.

If you do not opt out of medicare, then you need to bill medicare directly for providing said patient services, which typically is not something that cash only private practice psychiatrists want to deal with.
 
liquidshadow22 said:
I never said you are required to take any amount of medicare or medicaid patients for a private practice. I'm just saying if you want to see the patient and not accept their medicare, then you must opt out of medicare to charge them cash out of pocket. i.e. the patient has medicare but wants to see you for their care despite you not being in network with their govt insurance.

If you do not opt out of medicare, then you need to bill medicare directly for providing said patient services, which typically is not something that cash only private practice psychiatrists want to deal with.
Click to expand...

If you already know everything then why start this thread.
 
Members don't see this ad :)
Someone else answered my question. I'm just trying to explain the concept, no need to get defensive
 
calvnandhobbs68 said:
Yep that’s my understanding for Medicare. You’re either in or you’re out.

For Medicaid, it can be state specific and I’d look at your state laws. In some states, if both the provider and patients sign an agreement stating that all services will be cash only and absolutely nothing will be billed to Medicaid, you can have Medicaid patients in a cash practice even if you’re a Medicaid provider. Varies state to state though.
Click to expand...

Can you work inpatient and bill Medicare via an NPI-1, while having a private practice with its own NPI-2 that doesn't take Medicare?
 
Sushirolls said:
Yes, but if a Medicare pt knocks on your door at that different NPI-II practice, you can't take them in as cash only. Have to point them elsewhere.
Click to expand...

How do you get two different NPI numbers by the way?
 
NPI-I is your "social security number" of who you are as a physician.
NPI-II is the equivalent, but for a business identity.

I believe this website is where you go: Nppes.cms.hhs.gov/
 
TexasPhysician said:
Just have to refer the Medicare patients to another private practice. Can’t take them cash if you haven’t opted-out.
Click to expand...


So basically having two NPIs does not fix the issue is what you're saying. If you want to charge medicare patients cash out of pocket in your private practice then you must opt out of even doing an inpatient job that allows you to bill medicare.
 
Can the NPI-I be opted out so you can see Medi for cash outpatient, with an opted in NPI-2 you are contracted through for inpatient work?
 
Medicare is like glue to NPI-I, you.

Type two NPI numbers are more geared to private insurance. You can work for Big Box shop with their type 2 NPI, and they have a contract with their tax ID number and their type II NPI with insurance company Orange Religious Symbol. Your personal private practice can have its own type 2 NPI with its own tax ID number, with a worse contract with insurance company Orange Religious Symbol.

Ultimately its the Type II business/ tax ID that is submitting the bill, and you are the oversight, the necessary minor detail of type I for who actually did the service. But the type II / Tax ID holds the contract and they get paid.
 
TexasPhysician said:
No. There is no loophole. Medicare tracks you. You are out or in. Not in between depending on location.
Click to expand...

My understanding from what I've perused is that you can opt out your NPI-2 by filing an opt out, sending affidavits to local Medicare offices, requiring pts to sign an agreement they won't seek reimbursement with Medicare. So your NPI-2 can bill/charge any patient directly, whether they have Medicare or not. Is this true?

My understanding is also that absent a formal opt out, a patient who files for Medicare reimbursement places you on the hook as a Medicare provider. Is this correct?
 
Candidate2017 said:
My understanding from what I've perused is that you can opt out your NPI-2 by filing an opt out, sending affidavits to local Medicare offices, requiring pts to sign an agreement they won't seek reimbursement with Medicare. So your NPI-2 can bill/charge any patient directly, whether they have Medicare or not. Is this true?

My understanding is also that absent a formal opt out, a patient who files for Medicare reimbursement places you on the hook as a Medicare provider. Is this correct?
Click to expand...

Medicare follows your NPI - 1. Absent a personal opt-out, you can be penalized for charging patients with Medicare.
 
There is no NPI-II work around, back door, etc.
As Tex noted, if you are in as NPI-I (your personal NPI) it doesn't matter what the business entity that is employing you is doing.

However, I do believe buried some where in the medicare contract, if a NPI-II is in with medicare they cannot employee docs (NPI-I) who have opted out. They must ensure that all contractual dealings are with entities that haven't had medicare fraud issues, nor opted out.
 
Ironspy said:
I have turned away ~2-3 patients this year who had Medicare bc I participate in my main job but not in private practice. I make it clear online that I am all out of network in my private practice and screen all patients for insurance type prior to scheduling them for intake. I do not have anyone >55 in my private practice right now.

I have friends who have seen patients unknowingly with Medicare in cash private practice and had to return all that $ or risk committing Medicare fraud
Click to expand...
Should one assume that every patient age 65 and above has medicare?

Are there some patients age 65 and above who do not use medicare because they have better coverage through their work or through their significant others' work?
 
Username2015 said:
Should one assume that every patient age 65 and above has medicare?

Are there some patients age 65 and above who do not use medicare because they have better coverage through their work or through their significant others' work?
Click to expand...
Yes.

They will have Medicare as secondary insurance, but it's still there.
 
Username2015 said:
Should one assume that every patient age 65 and above has medicare?

Are there some patients age 65 and above who do not use medicare because they have better coverage through their work or through their significant others' work?
Click to expand...
In my area, At least 1/3 of older than 65 have Medicare advantage or Medicare HMO plans..... since these plans usually have narrow networks, I believe that you're able to charge them cash (unless you are in network with that plan)
 
Does it make sense for a cash practice psychiatrist to take Medicare in their practice if they also moonlight at hospitals as a Medicare provider.

So essentially would only participate with Medicare but be out of network with commercial insurances.

It seems Medicare reimbursement rates are not substantially different from commercial PPO in network reimbursement from what I'm seeing $170 per 99792, $80 for 99213, $120 99214 etc
 
liquidshadow22 said:
Does it make sense for a cash practice psychiatrist to take Medicare in their practice if they also moonlight at hospitals as a Medicare provider.

So essentially would only participate with Medicare but be out of network with commercial insurances.

It seems Medicare reimbursement rates are not substantially different from commercial PPO in network reimbursement from what I'm seeing $170 per 99792, $80 for 99213, $120 99214 etc
Click to expand...

You can definitely do this if you are willing to deal with Medicare billing and prices which are lower than many commercial plans and definitely lower than what you can charge cash. In many places, once word gets out that you accept Medicare in private practice you’ll get a lot of inquiries and could fill a practice with these patients.
 
michaelrack said:
In my area, At least 1/3 of older than 65 have Medicare advantage or Medicare HMO plans..... since these plans usually have narrow networks, I believe that you're able to charge them cash (unless you are in network with that plan)
Click to expand...
This is one of those grey zones I've been cautiously not doing cash pay arrangements for the random Medicare HMO or Advantage plan I'm not in network with. As long as I still have a Medicare in network status I'm not going to risk ticking off medicare.

But man, the concept of these HMO medicare plans, baffles me why any one signs up for these out side of being pushed into them by some nefarious broker.
 
Ironspy said:
You can definitely do this if you are willing to deal with Medicare billing and prices which are lower than many commercial plans and definitely lower than what you can charge cash. In many places, once word gets out that you accept Medicare in private practice you’ll get a lot of inquiries and could fill a practice with these patients.
Click to expand...

Still waiting to hear back from Bcbs and United, but heard back from cigna PPO and they were essentially offering Same rates as Medicare...why is billing and collection more cumbersome with Medicare in comparison to commerical insurance?
 
liquidshadow22 said:
Does it make sense for a cash practice psychiatrist to take Medicare in their practice if they also moonlight at hospitals as a Medicare provider.

So essentially would only participate with Medicare but be out of network with commercial insurances.

It seems Medicare reimbursement rates are not substantially different from commercial PPO in network reimbursement from what I'm seeing $170 per 99792, $80 for 99213, $120 99214 etc
Click to expand...

You can do that if you want. The "correct" way to do this is a membership-based practice where you charge a membership fee on top of the service fees. Remember, the issue here is that Medicare is below market--that's what you are trying to overcome.

By the way, these are all questions you can find by Googling and reading CMS guidelines. I suggest that if you want to start your own business you should aim to be through with your homework before asking strangers online, who may or may not have the right answers.


liquidshadow22 said:
Still waiting to hear back from Bcbs and United, but heard back from cigna PPO and they were essentially offering Same rates as Medicare...why is billing and collection more cumbersome with Medicare in comparison to commerical insurance?
Click to expand...

It's not. The more relevant issue is that Cigna PPO offers a different rate if you are negotiating from a large service provider with 100 MDs. In general if you take insurance you'll be using a billing service.
 
sluox said:
You can do that if you want. The "correct" way to do this is a membership-based practice where you charge a membership fee on top of the service fees. Remember, the issue here is that Medicare is below market--that's what you are trying to overcome.

By the way, these are all questions you can find by Googling and reading CMS guidelines. I suggest that if you want to start your own business you should aim to be through with your homework before asking strangers online, who may or may not have the right answers.




It's not. The more relevant issue is that Cigna PPO offers a different rate if you are negotiating from a large service provider with 100 MDs. In general if you take insurance you'll be using a billing service.
Click to expand...
What's a typical membership fee. This would be legal to do with Medicare patients?
 
Sluox, breathe. Deep breath.

95% of the topics on here are recycled topics and have been re-hashed several times if people simply search or dig thru the older threads. And interspersing that repetition is the "what are my chances thread?"

What's more sad, that people don't dig thru the repository of old threads or that older members (like you and I) continue to post the same things over and over? For instance, I like to comment about the warm and fuzzies of big box shops and the glory of private practice freedom. Whopper likes to comment about XYZ, Shufflin is laying low from his usual, Vistaril pops up like mole humps in the lawn every so often, etc, etc.

Try to remember the old adage, doctor means teacher, lets teach some stuff. At least here we don't have to fill out any darn feedback forms or join any committees.
 
Sushirolls said:
This is one of those grey zones I've been cautiously not doing cash pay arrangements for the random Medicare HMO or Advantage plan I'm not in network with. As long as I still have a Medicare in network status I'm not going to risk ticking off medicare.

But man, the concept of these HMO medicare plans, baffles me why any one signs up for these out side of being pushed into them by some nefarious broker.
Click to expand...
Can you tell me a bit more about this? Someone from the APA told me that if a patient has a Medicare Advantage plan, you can charge them directly. For regular fee-for-service Medicare, however, you cannot.

Is this your understanding?
 
TexasPhysician said:
Your doctor is wrong.
Click to expand...
I'm confused. Did they mean to say Medicare? With Medicaid, you're only going to get what the government is going to give, unless you're in a state where the patient can sign a waiver agreeing to pay for services outside of Medicaid covered providers.

That post also sounds like an ad to me.
 
birchswing said:
I'm confused. Did they mean to say Medicare? With Medicaid, you're only going to get what the government is going to give, unless you're in a state where the patient can sign a waiver agreeing to pay for services outside of Medicaid covered providers.

That post also sounds like an ad to me.
Click to expand...

Medicaid patients are free to pay cash for anything they want. They usually don't because they can't afford it, but that's a separate issue.

I have plenty of Medicaid/ACA equivalent patients whose parents front my bills. Medicaid covers emergency/catastrophic/medical bills.
 
sluox said:
Medicaid patients are free to pay cash for anything they want. They usually don't because they can't afford it, but that's a separate issue.

I have plenty of Medicaid/ACA equivalent patients whose parents front my bills. Medicaid covers emergency/catastrophic/medical bills.
Click to expand...
I'm pretty sure this is state dependent unless something has changed, and I was under the impression that in some states if a patient has medicaid the provider seeing them must then only accept medicaid as reimbursement or not see the patient. Although I have to say I have been utterly confounded in my own experiences as someone with Medicaid who has been told many different versions of what the law is. It seems even more confusing now that my state has "regular" medicaid as well as six managed medicaid plans offered by private companies, plans which some non-medicaid-providers seem to take.
 
birchswing said:
I'm pretty sure this is state dependent unless something has changed, and I was under the impression that in some states if a patient has medicaid the provider seeing them must then only accept medicaid as reimbursement or not see the patient. Although I have to say I have been utterly confounded in my own experiences as someone with Medicaid who has been told many different versions of what the law is. It seems even more confusing now that my state has "regular" medicaid as well as six managed medicaid plans offered by private companies, plans which some non-medicaid-providers seem to take.
Click to expand...

Medicaid is state specific, but I’ve never seen any state create a rule that limits physician availability if you can afford to pay cash. The physician may or may not have to sign some state form related to some nonsense in advance sure. Straight saying the government can ban access would be a good way to get voted out of office.

In many states, adoption of children comes with Medicaid for the child. You are saying that wealthy parents like Brad Pitt could take their bio children to concierge pediatricians, and then they go to a Medicaid clinic for their adopted children? There would be a media poo storm about how adopted children are forced to have substandard care in the family. As a parent, I’d be outraged if the state required me to treat my adopted child as lesser or just different than my bio child in any way. It costs me $20/month for my children to have access to a DPC family physician with private waiting areas. It doesn’t take a Brad Pitt to afford custom care, so he wouldn’t be the only one with a pitchfork.
 
TexasPhysician said:
Medicaid is state specific, but I’ve never seen any state create a rule that limits physician availability if you can afford to pay cash. The physician may or may not have to sign some state form related to some nonsense in advance sure. Straight saying the government can ban access would be a good way to get voted out of office.

In many states, adoption of children comes with Medicaid for the child. You are saying that wealthy parents like Brad Pitt could take their bio children to concierge pediatricians, and then they go to a Medicaid clinic for their adopted children? There would be a media poo storm about how adopted children are forced to have substandard care in the family. As a parent, I’d be outraged if the state required me to treat my adopted child as lesser or just different than my bio child in any way. It costs me $20/month for my children to have access to a DPC family physician with private waiting areas. It doesn’t take a Brad Pitt to afford custom care, so he wouldn’t be the only one with a pitchfork.
Click to expand...

Things must be very different down your way, fancy pediatric specialists/subspecialists in this area are waaay easier to see if the kiddos in question have the state children's medicaid plan than private insurance.
 
clausewitz2 said:
Things must be very different down your way, fancy pediatric specialists/subspecialists in this area are waaay easier to see if the kiddos in question have the state children's medicaid plan than private insurance.
Click to expand...

Not near me. Medicaid pays so low in my state that you’d be better off closing your practice than taking it. Other than large institutions that receive grants, no one takes it.
 
TexasPhysician said:
Not near me. Medicaid pays so low in my state that you’d be better off closing your practice than taking it. Other than large institutions that receive grants, no one takes it.
Click to expand...

Literally every child in my state is medicaid eligible and pediatric/child services generally push parents with commercial insurance to sign their kids up for Medicaid as secondary because it pays on far many more services than anyone else.

That's specifically the version for kids the state has beefed up, though, less so adults
 
clausewitz2 said:
Literally every child in my state is medicaid eligible and pediatric/child services generally push parents with commercial insurance to sign their kids up for Medicaid as secondary because it pays on far many more services than anyone else.

That's specifically the version for kids the state has beefed up, though, less so adults
Click to expand...

This is generally the case for most large hospital systems which provide the pediatric sub specialty care. They’ll be in network with the state Medicaid plan and usually most or all of the Medicaid managed care plans but private insurance is more hit or miss.
 
You must log in or register to reply here.

Similar threads

S
Practice Environment and Values
Replies
2
Views
116
comp1
C
T
Coverage for Private Practice - Opted Out Medicare
Replies
1
Views
1K
Sushirolls
Sushirolls
J
Attracting Medicaid Patients
Replies
7
Views
916
jbomba
J
yoloswagpoop42069
Cash Only Group Practice?
Replies
15
Views
2K
FlowRate
FlowRate
minimooshie
Private practice advice needed
Replies
15
Views
3K
minimooshie
minimooshie
Top