Taking insurance for 10 clients only

[Childdoconeday]

Hi all,

I am hoping to begin a private practice. I'm wondering if i do get paneled with an insurance, if i can choose to take only 10 insurance clients out of the 25 I hope to see a week. Thoughts?

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[medium rare]

Hi all,

I am hoping to begin a private practice. I'm wondering if i do get paneled with an insurance, if i can choose to take only 10 insurance clients out of the 25 I hope to see a week. Thoughts?

Technically, I don’t think insurances allow you to set a cap on how many of their insured you can see, but I know several people who do this, and really, it would be difficult for insurance companies to monitor this unless they were suspicious of fraud or some other type of wrongdoing that would get their attention. For that small of a number, I would suggest only getting on one panel or maybe two depending on your market (if you decide to do any at all) and schedule insurance referrals until you begin to get full. Once you are at your threshold, you can begin shifting your focus to self-pay patients and even consider getting off the panel.

One mistake I’ve seen people make in private practice is to join too many panels in an attempt to get busy quickly even though they want to eventually transition to self-pay or minimal insurance. If you join too many panels, you significantly limit the potential self-pay referrals because most self-pay patients have some form of insurance - they just choose not to use it if they want to see a provider who doesn’t take their insurance.

One thing to definitely avoid is being paneled on an insurance and agreeing to see a covered patient as self-pay. That’s a good way to trigger an audit and the ensuing mess that goes with it. And keep it mind, it can take several months to get off an insurance panel; it’s not as easy as it seems.

 

[PsyDr]

Usually, the contracts say that you can't "cap" how many patients you see with X insurance you see. They do check. There can be some state laws about this as well.

You can't say, "I can't take you because you have X insurance". You can say, "I can't take you because I do not perform those services, with those variables".

That's the professional version of "it's not you, it's me".

 

[singasongofjoy]

Technically, I don’t think insurances allow you to set a cap on how many of their insured you can see, but I know several people who do this, and really, it would be difficult for insurance companies to monitor this unless they were suspicious of fraud or some other type of wrongdoing that would get their attention. For that small of a number, I would suggest only getting on one panel or maybe two depending on your market (if you decide to do any at all) and schedule insurance referrals until you begin to get full. Once you are at your threshold, you can begin shifting your focus to self-pay patients and even consider getting off the panel.

One mistake I’ve seen people make in private practice is to join too many panels in an attempt to get busy quickly even though they want to eventually transition to self-pay or minimal insurance. If you join too many panels, you significantly limit the potential self-pay referrals because most self-pay patients have some form of insurance - they just choose not to use it if they want to see a provider who doesn’t take their insurance.

One thing to definitely avoid is being paneled on an insurance and agreeing to see a covered patient as self-pay. That’s a good way to trigger an audit and the ensuing mess that goes with it. And keep it mind, it can take several months to get off an insurance panel; it’s not as easy as it seems.

wait, what? Can you clarify on the self-pay matter? Are you sayin that's only if like the person then tried to file with the insurance themselves / didn't know that you were on the panel and accepted their insurance? In that case, makes sense of course. but if it is an agreement, like the client says "yeah, I've got insurance, but I don't want to use it I want to pay out of pocket so please don't bill the insurance / I'm not gonna give you my card... what then?

 

[foreverbull]

wait, what? Can you clarify on the self-pay matter? Are you sayin that's only if like the person then tried to file with the insurance themselves / didn't know that you were on the panel and accepted their insurance? In that case, makes sense of course. but if it is an agreement, like the client says "yeah, I've got insurance, but I don't want to use it I want to pay out of pocket so please don't bill the insurance / I'm not gonna give you my card... what then?

This may actually come up from time to time due to privacy preference (client has the funds to pay out of pocket and doesn’t want the insurance company to have therapy attendance on record in their system).

But I think you can still get into trouble with insurance companies if it is discovered (but how would it be discovered if the client never tried to get reimbursed via insurance)?

Most clients who pay out of pocket don’t tell you what insurance they have, but for folks who do take insurance, is it then up to you to ask to ensure it isn’t something you’re paneled on?

I’m also curious about this.

 

[WisNeuro]

You'd need to check applicable contracts and laws. I believe that for Medicare, if you have not opted out, you must file claims to Medicare for covered services, regardless of whether or not they want to pay out of pocket, otherwise it's considered fraud. Not completely sure for private insurers.

 

[medium rare]

wait, what? Can you clarify on the self-pay matter? Are you sayin that's only if like the person then tried to file with the insurance themselves / didn't know that you were on the panel and accepted their insurance? In that case, makes sense of course. but if it is an agreement, like the client says "yeah, I've got insurance, but I don't want to use it I want to pay out of pocket so please don't bill the insurance / I'm not gonna give you my card... what then?

You need to check the specifics of the insurance contract but, generally, the insurance carrier will prohibit the provider from taking self-pay from an insured patient. Some providers do do this with patients who request to self-pay but they need to make it explicit that the patient cannot submit a claim to insurance. This can work but there have been situations where the patient (or a spouse) tries to submit for reimbursement after the fact and, once insurance discovers this, they can come after the provider. Again, best to avoid this - way too risky, IMO.

And yes, with Medicare, you have to have officially opted-out to take self-pay Medicare patients. Otherwise, Medicare considers it fraud and will fine you substantially, even if you’ve never signed up as Medicare provider.

 

[foreverbull]

You need to check the specifics of the insurance contract but, generally, the insurance carrier will prohibit the provider from taking self-pay from an insured patient. Some providers do do this with patients who request to self-pay but they need to make it explicit that the patient cannot submit a claim to insurance. This can work but there have been situations where the patient (or a spouse) tries to submit for reimbursement after the fact and, once insurance discovers this, they can come after the provider. Again, best to avoid this - way too risky, IMO.

And yes, with Medicare, you have to have officially opted-out to take self-pay Medicare patients. Otherwise, Medicare considers it fraud and will fine you substantially, even if you’ve never signed up as Medicare provider.

For all practitioners to be considered automatically opted in to Medicare even if you didn't enroll and you don't get reimbursed by Medicare is rather ridiculous and confusing, in my opinion. Most practitioners just don't know this if they never enroll in insurance panels. I only know because I briefly enrolled in Medicare and then had to call to find out how to opt out. I have a private contract form that Noridian (my state's Medicare Administrative Contractor) supplied me to use with any client with Medicare coverage.

The links below provide some info about how/why to do so for any "new" private practitioners in our forum. Luckily, the "opt out" designation continues indefinitely (auto-renews every two years) unless you tell Medicare otherwise, although you will forever have to supply the private contract consent form to every new Medicare-insured client:

Opting Out and Private Contracting

Before treating Medicare beneficiaries, consider whether you want to accept Medicare's payment or contract privately with clients.

www.apaservices.org

Manage Your Enrollment | CMS

These resources are for health care providers and suppliers who are currently enrolled. Learn about PECOS, renewing your enrollment, opt-out affidavits, or withdrawing.

www.cms.gov

To opt out, you will need to:

• Be of an eligible type or specialty.
• Submit an opt-out affidavit to Medicare.
• Enter into a private contract with each of your Medicare patients. This contract will reflect the agreement between you and your patients that they will pay out of pocket for services, and that nobody will submit the bill to Medicare for reimbursement.

Contact your Medicare Administrative Contractor (MAC) (PDF) to see what information you should include in your opt-out affidavit and private contract.

 

[WisNeuro]

In terms of opting out, unless rules have been changed, you are out for 2 years aside from a 90 day window from when you first send the affidavit. So, make sure that you are going the PP route, as you may have a hard time getting hired in certain places if they cannot bill CMS for your services.

 

[clausewitz2]

In terms of opting out, unless rules have been changed, you are out for 2 years aside from a 90 day window from when you first send the affidavit. So, make sure that you are going the PP route, as you may have a hard time getting hired in certain places if they cannot bill CMS for your services.

I hate this rule. I have actually lost count of the number of older well-to-do professionals who have tried to establish with me in my private practice and are perfectly happy paying cash but I have to turn away because I work one day a week at a CMHC and so am not globally opted out.

 

[AcronymAllergy]

I hate this rule. I have actually lost count of the number of older well-to-do professionals who have tried to establish with me in my private practice and are perfectly happy paying cash but I have to turn away because I work one day a week at a CMHC and so am not globally opted out.

Agreed, it seems...dumb. There might be another reason for it, but it seems like there are basically a series of punishments devoted solely to discouraging providers from opting out.

 

[WisNeuro]

I hate this rule. I have actually lost count of the number of older well-to-do professionals who have tried to establish with me in my private practice and are perfectly happy paying cash but I have to turn away because I work one day a week at a CMHC and so am not globally opted out.

It'd be nice if it could be tied to an NPI II rather than a I. Would make things a lot easier.

 

[Sanman]

I hate this rule. I have actually lost count of the number of older well-to-do professionals who have tried to establish with me in my private practice and are perfectly happy paying cash but I have to turn away because I work one day a week at a CMHC and so am not globally opted out.

Agreed, one of the reasons I moved to VA practice is so that I could opt out in a side PP.

 

[AcronymAllergy]

Agreed, one of the reasons I moved to VA practice is so that I could opt out in a side PP.

I've never checked, but do we know VA providers can opt out of Medicare? I know VA technically bills insurance when applicable, so I'd figured they'd bill Medicare like anything else. But maybe there are rules about one government agency billing another?

 

[Sanman]

I've never checked, but do we know VA providers can opt out of Medicare? I know VA technically bills insurance when applicable, so I'd figured they'd bill Medicare like anything else. But maybe there are rules about one government agency billing another?

They don't. They do bill some private insurances including medicare supplementals. I did have to opt in as a provider to a private insurer when I onboarded with the VA. That is a much smaller issue for me than medicare/medicaid though.

Take this with a grain of salt as I have yet to dis enroll and try this.

 

[AcronymAllergy]

They don't. They do bill some private insurances including medicare supplementals. I did have to opt in as a provider to a private insurer when I onboarded with the VA. That is a much smaller issue for me than medicare/medicaid though.

Take this with a grain of salt as I have yet to dis enroll and try this.

Noted, thanks. And that's odd about the private insurance, I don't think I've ever heard of that. But maybe they just put it through without telling any of us here.

I'm actually opted-in currently anyway, so it's not as though it's directly applicable to me at the moment.