private practice: private pay pt later wants to bill medicare

[swisschard]

Hey all, long time, listener first time caller: I've been scouring the forums for the answer to this one, but can't seem to find an answer.

I recently started a private practice and am not contracted with any insurance providers but rather accept cash/credit card at time of visit. I went out and saw a patient for a home visit, had him sign a form ahead of time indicating he would be responsible for the fees associated w/ the intake (99205) as well as travel time to and from his home, billed at the same hourly rate. Now, after the visit I try to charge his card, it gets declined, and so I go back and talk to him, and he tells me he didn't realize he is responsible for the travel time (despite me being very clear about this ahead of time, and his signing a document agreeing to this at my hourly rate). Then, he has his mother call me and let me know that they are planning to bill his medicare (news to me that he had medicare). I never did opt out, nor did I sign up, and so I'm unclear what exactly my responsibilites are in terms of how much I can bill him, or if I have to bill medicare. I received half the fee from him so far. Can I only accept reimbursement up to the medicare set rate for a 99205 visit? What about billing him for travel time (he did sign a statement saying he would be responsible for that)?

Thanks.

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[Shikima]

Accept cash and payment ahead of time. They cannot bill medicare as you've not presented a superbill. They do not get the superbill until they pay. The rate agreed upon is cash only, not medicare rates as you're not providing medicare services or signed up for said services.

Sounds like you've been swindled.

 

[birchswing]

If you don't mind me asking, what are appropriate indications for home visits? Or is it not a matter of medical indication but more a matter of providing an extra service (like a luxury, I suppose)?

 

[F0nzie]

If a contract was signed you can always send an invoice with the remaining balance due. If they do not pay you can send them to collections.

Does Medicare even reimburse patients who submit super bills?

House calls are a big investment of time. Have you considered accepting payment upfront?


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[swisschard]

There was no medical necessity for a home visit in this case--for luxury/convenience.

Prior to scheduling him, I spoke with the guy over the phone before hand and said it's not my intent to base my practice on home visits, but rather that I offer it as a service to folks who want to pay more for the convenience, and so I charge the same hourly rate as for other procedures. I quoted him the estimated cost several times to confirm he was OK with it, and he stated he was. As I do with all my patients, I had him sign the intake paperwork detailing the fees for the intake, travel time, and more, along with him submitting his billing information (credit card # and all that jazz). I didn't get around to charging it until after the appointment because it looked alright, but when I did, the charge was denied, and the payment processor noted it is a prepaid debit card he gave me.

The contract/paperwork he signed outlines his responsibility for the fees, but doesn't say anything about medicare either way. After some light reading on the matter it seems like providers have to formally opt-out of medicare, and then if they take someone on who has medicare they must have the patient sign a detailed contract (they provide a sample) saying the payments are outside of medicare. Not sure if a contract of that extent is overkill but it probably makes settling ambiguous cases a lot easier. Still not entirely sure what my legal responsibilities are in this case.

 

[splik]

Hey all, long time, listener first time caller: I've been scouring the forums for the answer to this one, but can't seem to find an answer.

I recently started a private practice and am not contracted with any insurance providers but rather accept cash/credit card at time of visit. I went out and saw a patient for a home visit, had him sign a form ahead of time indicating he would be responsible for the fees associated w/ the intake (99205) as well as travel time to and from his home, billed at the same hourly rate. Now, after the visit I try to charge his card, it gets declined, and so I go back and talk to him, and he tells me he didn't realize he is responsible for the travel time (despite me being very clear about this ahead of time, and his signing a document agreeing to this at my hourly rate). Then, he has his mother call me and let me know that they are planning to bill his medicare (news to me that he had medicare). I never did opt out, nor did I sign up, and so I'm unclear what exactly my responsibilites are in terms of how much I can bill him, or if I have to bill medicare. I received half the fee from him so far. Can I only accept reimbursement up to the medicare set rate for a 99205 visit? What about billing him for travel time (he did sign a statement saying he would be responsible for that)?

Thanks.

the answer is if you are indeed a medicare provider then you cannot charge patients out of pocket for services covered by medicare. medicare doesn't pay superbills so the patient couldn't get partial reimbursement from them and you can't charge more for covered services (i.e. the 99205) than they pay. At the same time you can charge medicare patients cash for services that they do not cover (for example travel time to and from that the patient signed a contract for).

Where this gets murky is that it appears the patient failed to disclose he had medicare for you in the first place. I suspect this doesn't alter anything because the onus is on you to know (and it sounds like you didn't).

If you don't wish to opt-out of medicare then you will need to make it clear that you are not taking medicare patients (if you don't wish to do so). It sounds like you would be a non-participating physician (which means you are enrolled but not participating) which means you can charge up to 115% of medicare allowed amount for claims. You can also charge cash for any services not covered by medicare. To give you an example, wealthy elderly medicare patients might enrol in a concierge practice. The physician is able to charge an annual retainer (say $20k) but cannot charge extra for any services covered by medicare and will bill medicare for those services (for example 99213 office visit, chest x-ray, labs etc).

In sum, as a non-participating provider you have to bill medicare (up to 115% of allowed amount for 99205) for seeing a medicare patient and cannot accept cash for this. however you can charge cash for travel time as that was agreed beforehand and would not be covered by medicare. In future be more careful about screening patients and accepting their credit card up front. I don't do pp but if I were doing this kind of thing I might be inclined to use square and process the credit card there and then. If you wanna charge cash you should get comfortable with this.

 

[TexasPhysician]

You are doing things wrong.

Unless you opt-out of Medicare and have patients sign a contract waiving their Medicare rights then you almost automatically agree to bill Medicare. That is how the government sets things up to force Medicare upon us. The patient could actually complain to Medicare and have all fees returned if you provided a Superbill.

Cash Medicare patients should not receive a Superbill. This is part of the opt-out process.

 

[westlaker]

Unless you opt-out of Medicare and have patients sign a contract waiving their Medicare rights then you almost automatically agree to bill Medicare. That is how the government sets things up to force Medicare upon us. The patient could actually complain to Medicare and have all fees returned if you provided a Superbill.

Cash Medicare patients should not receive a Superbill. This is part of the opt-out process.

Wow, learning !

What if I work in an in-pt setting in the morning and bill Medicare for the service I provide, then I work in my cash-only PP in the afternoon? I can not tell if the patients I see are on Medicare or Medicaid if they choose to hide that info from the me, similar to the situation OP ran into.

 

[downwithDTB]

Maybe I am totally and completely confused... Is the point here that any provider who doesn't explicitly op out of Medicare can't charge someone with Medicare more than $x for a Medicare covered service? Or is there something deeper going on? If that's the case where do the feds derive the ability to regulate intrastate practice... My mind is being totally blown here..

 

[OldPsychDoc]

... where do the feds derive the ability to regulate intrastate practice...

Umm, the US Constitution?
(Article 1, Section 8, Clause 3)

 

[swisschard]

DownwithDTB: exactly. it's crazy.

westlaker: I'm in a similar situation. I work part time as a per diem in other facilities that want me to register as a medicare provider, which seems like it would conflict with a cash based private practice. I'm trying to figure out if it's worth it or not...

texasphys and splik: So I think in my situation I can still charge the travel time fees, but have to reimburse for some of the 99205 fee, and then submit a bill to medicare. Does this sound right?


My further study reveals if you register under medicare, you charge medicare for reimbursement after collecting a copay from the pt. If you don't register, you can only charge so much money, which is 115% of 95% of the reimbursement rate for the CPT code, and then you submit the charge to medicare, who reimburses the patient. If you opt-out, you're free to charge whatever you like, as long as you get your pt to sign a contract with some particular verbage.

 

[VA Hopeful Dr]

So as a cash-only family doc (who has spent a small fortune in legal fees on this very subject), allow me to tell you how this works.

Unless you have specifically opted-out of Medicare, then you cannot charge Medicare patients more than the Medicare allowable for covered services (or the 115%, however that only applies if you never bill Medicare and it sounds like you do at your inpatient job). This means that your 99205 must be at the Medicare rate. I am unsure about travel time, as I believe Medicare does have a code for home visits that supposedly is higher to cover travel expenses.

Long story short, if you are a Medicare provider then I would not even bother seeing Medicare/Caid patients cash-only. Best case you don't earn very much, worst case CMS sues you.

 

[downwithDTB]

Umm, the US Constitution?
(Article 1, Section 8, Clause 3)

"To regulate Commerce with foreign Nations, and among the several States, and with the Indian Tribes."

My understanding was that a business operating soley within the confines of a single state couldn't be regulated federally... I understand that I'm wrong but was curious as to what the logic is...

Im also guessing that it's not possible to set up a business (eg llc) for your private practice where you operate as a Medicare non-provider but provide services through a hospital?

 

[PsyDr]

Additional piece: without opting out, medicare can refuse to pay for the resulting medications and labs prescribed.

 

[TexasPhysician]

Wow, learning !

What if I work in an in-pt setting in the morning and bill Medicare for the service I provide, then I work in my cash-only PP in the afternoon? I can not tell if the patients I see are on Medicare or Medicaid if they choose to hide that info from the me, similar to the situation OP ran into.

It's quite tricky. The patients that have Medicare can lie and say they don't. Then after receiving care, they can request their money back (you are a Medicare provider), and you must return the money. Then you bill Medicare. It's illegal if you don't.

 

[splik]

It's quite tricky. The patients that have Medicare can lie and say they don't. Then after receiving care, they can request their money back (you are a Medicare provider), and you must return the money. Then you bill Medicare. It's illegal if you don't.

although it's a pretty good bet that if your patient is over 65, receiving SSDI payments for over 2 years, had ESRD or ALS that they have medicare so it's not like they are not identifiable. It's pretty sneaky if patients are telling you about having Medicare and then wanting to bill it afterwards, that means they would have to know about the medicare billing laws (which as this thread illustrates not all physicians even understand..) naughty patients...

 

[splik]

So as a cash-only family doc (who has spent a small fortune in legal fees on this very subject), allow me to tell you how this works.

Unless you have specifically opted-out of Medicare, then you cannot charge Medicare patients more than the Medicare allowable for covered services (or the 115%, however that only applies if you never bill Medicare and it sounds like you do at your inpatient job). This means that your 99205 must be at the Medicare rate. I am unsure about travel time, as I believe Medicare does have a code for home visits that supposedly is higher to cover travel expenses.

medicare does cover home visits but only for patients who have been certified as homebound as have one or more of the following needs: skilled nursing care, PT, OT, speech therapy. If it's for convenience they won't pay for it and you are within your right to charge for it.

 

[TexasPhysician]

although it's a pretty good bet that if your patient is over 65, receiving SSDI payments for over 2 years, had ESRD or ALS that they have medicare so it's not like they are not identifiable. It's pretty sneaky if patients are telling you about having Medicare and then wanting to bill it afterwards, that means they would have to know about the medicare billing laws (which as this thread illustrates not all physicians even understand..) naughty patients...

This is exactly Medicare's argument. They will say that the law is simple and clear. Billing normal cash rates is therefor fraud.

I doubt a patient or 2 causes a stink other than refunding money, but a continuous disregard of the law may land someone in hot water.

 

[michaelrack]

although it's a pretty good bet that if your patient is over 65, receiving SSDI payments for over 2 years, had ESRD or ALS that they have medicare so it's not like they are not identifiable..

some have the private medicare/medicare advantage plans that have different rules

 

[VA Hopeful Dr]

medicare does cover home visits but only for patients who have been certified as homebound as have one or more of the following needs: skilled nursing care, PT, OT, speech therapy. If it's for convenience they won't pay for it and you are within your right to charge for it.

I would want an attorney to confirm that before you start charging Medicare patients cash for home visits beyond the office CPT codes

 

[swisschard]

I am trying to figure out if its the same policy for Medicaid patients as it is for Medicare. Can anyone comment? Thanks.

 

[michaelrack]

I am trying to figure out if its the same policy for Medicaid patients as it is for Medicare. Can anyone comment? Thanks.

It's different for medicaid- there is no opting out. YOu are either in medicaid for a state or you aren't. If you aren't, I think you can charge the patient an agreed upon fee

 

[whopper]

In general I wouldn't recommend house calls unless you trust the patient. You could be walking into a cluster B patient's trap. E.g. they might make a sexual advance on you, the person might have a questionable lifestyle (e.g. be a member of the mafia), and when on someone's home turf a lot of legal protections and rights are washed away.

E.g. many states have a castle doctrine, that is a lot of things in the home the owner can do that he otherwise can't do in public cause it's his home including shooting someone on his property if he feels threatened. While such cluster-B patients are rare they are out there and you are walking into their home for the first time not even having evaluated them yet.

The job I have now a lot of the usual headache patients I used to have I don't have. The place I'm at is in high-end part of town, the practice has a good rep, and we got a lot of private pay patients. Already about 1/4 of my patients are private pay and I've only been doing this 4 months.

But a lot of my prior jobs I wouldn't trust anyone of my patients, none of them until I had them for at least a few months.

 

[swisschard]

It's different for medicaid- there is no opting out. YOu are either in medicaid for a state or you aren't. If you aren't, I think you can charge the patient an agreed upon fee

Thanks! I think I understand but do correct me if I'm wrong: So physicians who don't specifically enroll in Medicaid aren't bound to accept their fee structure, but can set their own? (unlike Medicare where this is the default for ALL providers)

 

[Psychotic]

It's different for medicaid- there is no opting out. YOu are either in medicaid for a state or you aren't. If you aren't, I think you can charge the patient an agreed upon fee

But...if someone is on medicaid, how can they afford to pay much of anything? Sure, you can charge them, but getting paid is another thing...

 

[notdeadyet]

In general I wouldn't recommend house calls unless you trust the patient.

Boy, Whopper's post is spot on. Aside from BPD and ASPD shenanigans, I just have general fear of litigation when I'm practicing outside of standards. Homebound patient's is one thing, but otherwise...

wcryan- have you checked with your malpractice provider about home visits and limitations of liability?

 

[swisschard]

Boy, Whopper's post is spot on. Aside from BPD and ASPD shenanigans, I just have general fear of litigation when I'm practicing outside of standards. Homebound patient's is one thing, but otherwise...

have you checked with your malpractice provider about home visits and limitations of liability?

I did not fully consider the potential problems with home visits and PD patients--might be worth avoiding for that reason.

Though how are home visits for convenience outside the standard of care? As long as one is doing a full evaluation, monitoring labs and s/e appropriately, and seeing them at an interval c/w standard of care I have a hard time believing malpractice could opt not to cover such visits.

 

[michaelrack]

But...if someone is on medicaid, how can they afford to pay much of anything? Sure, you can charge them, but getting paid is another thing...

I wouldn't recommend a private contract with a medicaid pt. However, some of them do have off- -the -books sources of income such as prostitution and selling drugs (or legal odd jobs/handiwork/errands). Many of my medicaid inpatients (as well as lower income non-medicaid, as well as a lot of my inpatients in general) find a way to pay for marijuana.

 

[notdeadyet]

As long as one is doing a full evaluation, monitoring labs and s/e appropriately, and seeing them at an interval c/w standard of care I have a hard time believing malpractice could opt not to cover such visits.

Check with your malpractice insurer. Should be a quick phone call and you're fine. But I wouldn't want to be sued when a patient with BPD claims rape or a patient has a fall during your visit or _____ and find out that the fine print indicates that my malpractice insurance is limited to office environments.

I'm also curious if there are any issues with business liability insurance or if a physician making housecalls auto insurance is required to have a commercial flag.