Opting out of medicare - implications?

[VeryOldSpice]

Hey all, I'm starting a cash only private practice when my residency ends in 6 weeks and planning on working some side gigs in the mean time. I was going to opt out of Medicare/Medicaid to be able to take these patients in my private practice, however one of the tele companies I was planning to work for requires you to be opted in. I'm in the state of Florida, I spoke with Florida Medicare and they confirmed if you are opted in as a provider that means you are opted in at all locations that you work at, meaning I definitely won't be able to take these patients as cash payers.

One option I have is to stay opted in and not accept any Medicare/Medicaid patients in my private practice. Other option is to skip joining that tele company and find something else so I can opt out.

1. Would a cash only private clinic get many cash-pay Medicare/Medicaid patients? Am I significantly limiting myself by staying opted in?
2. What other implications does opting out have on my future career?
3. How hard would it be to find clinic based side gigs that don't require me to be opted in?

Thanks so much for your help!

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[Sushirolls]

Medicare really is a pain in this regard.

Opting out means you can't opt back in until 2 years have lapsed... thanks medicare.

As long as you are "in" even if from residency days or a new first attending job, you are "in"

However, you can't bill medicare unless your NPI I, NPI II if you have one, Tax ID, and office location are all established as IN NETWORK, then you can bill medicare AND get paid for it. Otherwise, those bills are denied/rejected, etc

What I do with my private practice is stay opted in. To keep open the idea of employed jobs in future. I've recently take on some medicare patients, but those companies that have their advantage plans that are a pain, I just don't, and am OON for. I tell those patients, sorry can't help you. But because I am in network, I don't want to risk even attempting to do cash only for any of those patients. In the past I simply told all medicare "I am at capcity" and not taking on new patients, which any private clinic can do. However, nonprofits cannot limit their medicare... even though I've seen it before.

Unless you are a truly commited to cash only, and have no intention to ever, ever work an employed job again, I'd say don't opt out - yet. When the day comes you are truly cash only, and completely commited, then opt out. Some commercial insurance requires active medicare as part of their enrollment. Many hsopital priviliges do, too.

In grand summary, truly 100% cash only peeps, opt out and don't look back, every one else, you stay in.

 

[nexus73]

of course you’d never opt out…

because of the implication

 

[PikminOC]

of course you’d never opt out…

because of the implication

Yes then you can't do locums

 

[Fpg1245]

Can someone have multiple NPI numbers?
Use one for Medicare and have a spare for not.

 

[nexus73]

Can someone have multiple NPI numbers?
Use one for Medicare and have a spare for not.

No, medicare is all in or all out as the physician. Can’t split out different identifiers or business entities to get around it. They feds don’t want doctors to opt out.

 

[WisNeuro]

Can someone have multiple NPI numbers?
Use one for Medicare and have a spare for not.

You can have a separate NPI for a clinic (NPI II) but you'd still be logging your NPI I as the rendering provider, so, no dice as far as I know.

 

[Fpg1245]

what about Medicare advantage plans? Can you be OON with those? And still take straight Medicare?

 

[WisNeuro]

what about Medicare advantage plans? Can you be OON with those? And still take straight Medicare?

For managed care plans, you need to be in network with that insurance company, with a few exceptions. If anything, straight medicare, or medicare with supplemental are the easiest to deal with. Some MA plans are an absolute PITA.

 

[Fpg1245]

For managed care plans, you need to be in network with that insurance company, with a few exceptions. If anything, straight medicare, or medicare with supplemental are the easiest to deal with. Some MA plans are an absolute PITA.

So if you are in network with UHC. You have to take all their plans? Who negotiates those rates?

 

[WisNeuro]

So if you are in network with UHC. You have to take all their plans? Who negotiates those rates?

You, or your clinic/organization does.

 

[Sushirolls]

Each insurance company lines up their flavors of insurance differently on their contracts.

Commercial / private insurance [check this box]
Medicare Advantage plan [check this box]
medicaid plan [check this box]

Sometimes they really break them out and you can pick and choose. Just have to remember which you are in with, and not.

One company I recently signed up for in my new state / location, lumped their Medicare advatange, their HMO medicare and Medicaid in one check box. I didn't want medicaid, definitely not the HMO, so I didn't check it. Now my assistant and I always have to remember, to Medicare of any type from this company.

What @WisNeuro said above in post #9, so true. So true.

 

[minimooshie]

Just a basic question on this topic - starting a cash PP, so I could just post in my screening tools/website etc that I am not able to accept Medicare patients, correct? I don't want to opt out in case I want to pick up an ER side gig or something in the next couple years.

I am technically a (one-person) corporation so I don't know if that means I can't advertise the fact I can't see Medicare patients. I can ask my lawyer that one, too.

 

[Stagg737]

Just a basic question on this topic - starting a cash PP, so I could just post in my screening tools/website etc that I am not able to accept Medicare patients, correct? I don't want to opt out in case I want to pick up an ER side gig or something in the next couple years.

I am technically a (one-person) corporation so I don't know if that means I can't advertise the fact I can't see Medicare patients. I can ask my lawyer that one, too.

Correct. You should be able to do cash only, but patients can't have Medicare. My understanding is that you can still see Medicare patients, but that you'd be billing Medicare and cannot charge them the cash rates. I'm not 100% certain on that though, so I'd defer that to others with more experience in the PP arena.

 

[Jules A]

Just a basic question on this topic - starting a cash PP, so I could just post in my screening tools/website etc that I am not able to accept Medicare patients, correct? I don't want to opt out in case I want to pick up an ER side gig or something in the next couple years.

I am technically a (one-person) corporation so I don't know if that means I can't advertise the fact I can't see Medicare patients. I can ask my lawyer that one, too.

I have a line on my office policies document that requires patient initials indicating I don’t accept Medicare patients. My advertising includes the out of network information but doesn’t specifically mention Medicare.

On a side note I’m not sure if you were being literal about incorporating but I don’t think there is usually value in a one person operation doing anything other than sole proprietorship?
I always wonder where new docs find cash practice patients. My referrals are almost exclusively from past or present colleagues and current patients. I know one who took over a cash practice when the psychiatrist moved out of the area but I don’t think that is a common occurrence.

 

[mistafab]

Just my 2 cents, but I would not opt out if you are planning to do side gigs while your practice is growing. Who knows how long it will take your cash practice to build a sizeable panel and be enough to sustain you. 6 months? 1 year? 2 years?

I would stay opted in after residency until your PP is established. Then you can opt out since you won't need the other gigs. Opting out will just make it hard for your to do any kind of side work.

 

[Psychferlyfe3000]

Can someone clarify: If I have an S-Corp and am seeing BCBS exclusively as a 1099, is that considered opting out? Thanks.

 

[Jules A]

Can someone clarify: If I have an S-Corp and am seeing BCBS exclusively as a 1099, is that considered opting out? Thanks.

To opt out you actually have to opt out.

 

[minimooshie]

On a side note I’m not sure if you were being literal about incorporating but I don’t think there is usually value in a one person operation doing anything other than sole proprietorship?

I'm in CA and was told I have to have a Corporation in order to have a medical practice. Might be different in other states. I have a colleague with an LLC in PA for example.

 

[Jules A]

I'm in CA and was told I have to have a Corporation in order to have a medical practice. Might be different in other states. I have a colleague with an LLC in PA for example.

Interesting I wasn't aware of that. For LLCs my understanding is also that it is unnecessary for one person practice because sole proprietor is generally sufficient.

 

[Sushirolls]

I've heard that about some states that some sort of corporation is necessary.

Another thing I've heard is that some states LLC is good for most all businesses but professionals of CPA, Lawyer, doctor etc, must use PLLC

 

[Dr. M Toboggan]

I recently binged the entire PP thread made by @Sushirolls (awesome by the way) because I am finishing residency this year and looking to start a PP on the side. I have always thought about doing a cash clinic, but I do not know if the Midwest city I will be moving to can sustain a cash clinic, so I am a bit hesitant. There are a few APRNs in town taking cash, a bunch of APRNs taking insurance, and very few MD/DOs in solo PPs. Most providers are out of state/virtual. As I plan to take a full time gig immediately after residency while I build the clinic, I am trying to come up with options that would more easily allow one to opt out of Medicare for cash practice purposes. Below is the long list of options I have thought of:

1. VA
2. ...
3. ...

Okay, so one option. Can anyone else offer ideas of main gigs that would more easily allow one to run a cash practice without worrying about accidently taking on an "undercover" Medicare patient?

 

[ObsequiousAplomb]

I recently binged the entire PP thread made by @Sushirolls (awesome by the way) because I am finishing residency this year and looking to start a PP on the side. I have always thought about doing a cash clinic, but I do not know if the Midwest city I will be moving to can sustain a cash clinic, so I am a bit hesitant. There are a few APRNs in town taking cash, a bunch of APRNs taking insurance, and very few MD/DOs in solo PPs. Most providers are out of state/virtual. As I plan to take a full time gig immediately after residency while I build the clinic, I am trying to come up with options that would more easily allow one to opt out of Medicare for cash practice purposes. Below is the long list of options I have thought of:

1. VA
2. ...
3. ...

Okay, so one option. Can anyone else offer ideas of main gigs that would more easily allow one to run a cash practice without worrying about accidently taking on an "undercover" Medicare patient?

corrections

 

[calvnandhobbs68]

Interesting I wasn't aware of that. For LLCs my understanding is also that it is unnecessary for one person practice because sole proprietor is generally sufficient.

Unless there's some state law that requires you to setup a corporation of some sort (idk about California), a sole prop is basically the same as a solo LLC for tax and liability purposes unless you're planning on owning your own office or something.

An LLC does give you some more flexibility in terms of being a more "official" business and expanding going forward....also helps to separate out things financially but that doesn't matter too much if you're single member LLC as for tax purposes you're essentially the same. And yes in some states you have to be a "PLLC" if you're a professional establishing an LLC.

 

[Jules A]

I recently binged the entire PP thread made by @Sushirolls (awesome by the way) because I am finishing residency this year and looking to start a PP on the side. I have always thought about doing a cash clinic, but I do not know if the Midwest city I will be moving to can sustain a cash clinic, so I am a bit hesitant. There are a few APRNs in town taking cash, a bunch of APRNs taking insurance, and very few MD/DOs in solo PPs. Most providers are out of state/virtual. As I plan to take a full time gig immediately after residency while I build the clinic, I am trying to come up with options that would more easily allow one to opt out of Medicare for cash practice purposes. Below is the long list of options I have thought of:

1. VA
2. ...
3. ...

Okay, so one option. Can anyone else offer ideas of main gigs that would more easily allow one to run a cash practice without worrying about accidently taking on an "undercover" Medicare patient?

You are probably overthinking this. I wouldn’t base my full time job selection on trying to avoid Medicare due to worries that a Medicare patient will somehow slip in unannounced and then report you. Especially when the options appear to be VA and corrections.

 

[Dr. M Toboggan]

You are probably overthinking this. I wouldn’t base my full time job selection on trying to avoid Medicare due to worries that a Medicare patient will somehow slip in unannounced and then report you. Especially when the options appear to be VA and corrections.

The full-time gig would hopefully be temporary (up to a few years) as the clinic grows. If cash clinic not viable, would likely switch to insurance-based practice.