Private Practice World

[clement]

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Seeking general words of wisdom from people who moonlight and also do some private practice ...Relatively recent grad. I'm thinking about a small cash-only private practice 1-2 days per week.
I'm a indep contractor/per diem in an ED (mostly indigent patient pop) with a group (in a different region of my state). Upon credentialing, they are asking me to panel with insurances (medicare ppo's/hmo's, and non-medicare ppo's/hmo's).
I know for medicare (?and medicaid) if your private practice address isn't listed with them (as opposed to a hospital or group's info), it's not a big deal. I was told the group's address and tax id are listed, so don't worry, but the paperwork was asking me to contract as an individual provider with the group's address. When I contacted the insurance rep, they said the individual physician still has to contract with them (and see their patients in my private practice). Anyone have experience with this and would you just not agree to panel? It's all very confusing.

 

[TexasPhysician]

It is confusing and you may need an attorney. Medicare is only by individual. If you accept Medicare anywhere and/or don’t formally opt-out, you must accept it everywhere.

 

[clement]

Not sure on the medicare opting out. I know people who do not see medicare patients in private practice but are listed as participating providers with their salaried positions using the employer's address/info, not the private practice (meaning they didn't opt out). Maybe you mean a person doesn't opt out but is a non participating provider for their private practice? The thing is, I only moonlight 5-6 shifts per month, so I'm not sure paneling me with 5 zillion insurances is necessary anyway...

 

[dl2dp2]

Common question and insurance companies give you answers you can't use--they are just saying, in order for the practice to bill under your name, you must be in network at the hospital. This doesn't say anything in terms of whether you also have to be in network at your own practice. However, they will not give you a straight answer because they want you to apply to be in network in private practice as well. Generally speaking, private insurance panel by facility address (since difference facilities have separate contracts and often have carve outs which have different fee schedules). Medicare is by provider, same rate everywhere. You should be safe. However, you can't take Medicare patients in private practice and charge them private fee.

In reality, it doesn't matter. If you are opted out in Medicare, and sign paperwork with hospital to be credentialed, typically what happens is that the hospital attempts to credential you, then gets rejected. Then it just continues. If you see a Medicare patient, your visit is free care because Medicare will reject the claim. The hospital will have a biller rebill a few times and give up. It'll be written off as charity care.

 

[clement]

Excellent. What I understand now is this:

If it's private insurance the group is paneling me with, i.e. PPO or HMO "X," using just my name, NPI, and the group's hospital address on the paperwork, I could still see those patients in my cash-only practice and charge my private rates-- I was worried because I did not see the group's name on the physician paneling paperwork even though they use their address and would bill with their tax ID. I could come off of most of these private insurance panels easily, anyway, if needed, or so I believe.

If it's Medicare PPO or HMO "X" (and this is where I got confused) with which the group is paneling me with (using my name, NPI, and the hospital's address), then it's a matter of a) NOT opting out, but remaining a non-participating provider (and therefore still being able to bill your private rate when seeing Medicare patients-- but it's a pain to get paid) or b) opting out (which is less realistic if you also work for a hospital, like a county hospital and you can't opt back in for a long time) or c) NOT opting out but simply not seeing Medicare patient's in your private practice (and keeping an eye on patients who turn 65 in case they become Medicare patients).

 

[michaelrack]

I believe opting out only applies to regular Medicare, and not the Medicare hmo's