Taking insurance in a hospital while not doing so in private practice

[treckingon]

Hello,

I am a clinical psychologist in private practice and am considering taking a part time job at a hospital. I do not take insurance in private practice and I know I'll have to go on insurance panels in order to work on staff at the hospital. Will I be required to take insurance in private practice as well once I get on insurance panels as part of the hospital staff?

Who would I contact to find out the facts on this?

Thank you!

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[smalltownpsych]

Off the top of my head, I don't see why this would be a problem since it is two separate businesses. To be on the safe side, you probably should consult with an attorney. If you have the Trust, you could always consult them first for free and if they can't answer they could refer you to someone appropriate in your area.

 

[foreverbull]

You might contact your go-to for ethical issues, such as malpractice carrier hotline just to double-check.

 

[WisNeuro]

The real issue is actually whether or not you opted out of medicare/Medicaid, as most hospitals will require you accept it. If you do, I don't believe that you can make those patients pay cash if they would like to use their medicare/aid benefits.

 

[AcronymAllergy]

In addition to folks here, I'm pretty sure there's a thread or two about this topic in the Psychiatry forum that might be helpful. You may have to search for it, though.

 

[Therapist4Chnge]

i believe you need to have a different tax ID associated with your practice than with the hospital. This would help keep it cleaner in regard to billing.

As for Medicare...ugh, they are a hassle. It’s easiest to not even see Medicare in PP, but if you do...accept their rates bc “opting out” is on you and having to contact them each time you see a Medicare patient and have proof that the patient understands they are not using their benefits. I forget if you need “proof” from CMS about it, or just a copy of a signed form from the patient. I believe your “opt out” needs to be renewed. It’s been awhile since I looked at this stuff, so YMMV on the details. I just know you don’t want to screw with CMS.

No idea about Medicaid, but it’s likely a hassle too.

 

[PsyDr]

You have to create a separate LLC, with a unique EIN; then get a unique NPI for the LLC as a facility, and potentially a UPIN for the same. Then get contracts with the insurance companies for the LLCs.

If you do not do this, you will have to take those insurances in your private practice.

 

[foreverbull]

You have to create a separate LLC, with a unique EIN; then get a unique NPI for the LLC as a facility, and potentially a UPIN for the same. Then get contracts with the insurance companies for the LLCs.

If you do not do this, you will have to take those insurances in your private practice.

I was under the impression that each setting is discrete for insurance paneling, to some extent...

For example, if you work for a company contracting with hospitals and get paneled on Medicare via the hospital, you can't just start billing Medicare in private practice for Medicare clients; you must enroll your private practice LLC or group business, then reassign your fees to the organization. If you don't enroll in Medicare in private practice, I'm not understanding why you wouldn't be simply private pay, which is discrete from your practice with your employer in the hospital setting, since Medicare requires enrollment/reassignment for any site in which you want to bill Medicare.

 

[Therapist4Chnge]

The rub is that you are enrolled in Medicare as the default. This is why you need a separate tax ID for your PP and you have to take extra steps to opt-out for your PP. Commercial insurance is all opt-in.

 

[PsyDr]

@foreverbull

I'm not an expert at billing at all. But I believe you are incorrect for every insurance, EXCEPT for medicare/medicaid.

There is Type 1 and Type 2 NPIs. The former is the one everyone has. The latter is for LLCs, INCs, clinics, etc. Functionally, this means who did the work (NPI Type 1) and who gets paid (NPI Type 2). But you can also just get paid under a type 1. A provider can get an type 1 NPI, create an LLC, get an type 2 NPI on the LLC, and bill that way. One can also get an NPI, and have your hospital bill for you under their type 2.

What you seem to be describing is VERY specific to medicare/medicaid. In CMS, there is an additional identifier called a PTAN. This unique alphanumeric identifies each location in which a provider works. In your case, the provider has an NPI, is enrolled in medicare/medicaid, receives a PTAN for that location, bills under a type 2 NPI and a secondary type 1, and reassigns benefits to the contracting agency. The PTAN is generally not used with commercial insurances unless they are replacement policies. I believe in your scenario, the provider could very easily request another PTAN, receive it very quickly, and begin billing CMS at your private practice.

 

[foreverbull]

@foreverbull

I'm not an expert at billing at all. But I believe you are incorrect for every insurance, EXCEPT for medicare/medicaid.

There is Type 1 and Type 2 NPIs. The former is the one everyone has. The latter is for LLCs, INCs, clinics, etc. Functionally, this means who did the work (NPI Type 1) and who gets paid (NPI Type 2). But you can also just get paid under a type 1. A provider can get an type 1 NPI, create an LLC, get an type 2 NPI on the LLC, and bill that way. One can also get an NPI, and have your hospital bill for you under their type 2.

What you seem to be describing is VERY specific to medicare/medicaid. In CMS, there is an additional identifier called a PTAN. This unique alphanumeric identifies each location in which a provider works. In your case, the provider has an NPI, is enrolled in medicare/medicaid, receives a PTAN for that location, bills under a type 2 NPI and a secondary type 1, and reassigns benefits to the contracting agency. The PTAN is generally not used with commercial insurances unless they are replacement policies. I believe in your scenario, the provider could very easily request another PTAN, receive it very quickly, and begin billing CMS at your private practice.

This may be. I enrolled in Medicare at one point, so I'm only familiar with Medicare rules. I do know that you can't take Medicare in your PP without registering the business, specifying that you work in that business, and then reassigning your benefits to the business entity (NPI 2). By the same logic, if you don't register your business for Medicare (specifically your PP), you can't take Medicare in your PP.

However, I've never enrolled in Anthem, BCBS, etc. If those are all opt-in by default, there may be set rules about having to accept it in every setting, regardless of site employed at, so that's something that folks who take those insurances would have to respond to.

The OP should check with each insurance company paneled in.

 

[Peacemaker36]

If you are credentialed as a Medicare provider with the hospital, you are required to accept Medicare in your PP, no exceptions. This is federal law. I contacted APA and Medicare to verify this a few years ago. I suppose it's possible the laws have changed but I doubt it.

Note: people do break this law, and I don't know how many get caught. I wouldn't advise it.

 

[foreverbull]

If you are credentialed as a Medicare provider with the hospital, you are required to accept Medicare in your PP, no exceptions. This is federal law. I contacted APA and Medicare to verify this a few years ago. I suppose it's possible the laws have changed but I doubt it.

Note: people do break this law, and I don't know how many get caught. I wouldn't advise it.

Can you clarify whether this means you come in as a private contracted employee and get paneled under your business but work at the hospital, or the hospital took care of your credentialing and you're taking Medicare at the hospital site you work at per your Medicare application?

Under this scenario, why would you ever have to do a bunch of extra paperwork to enroll your business/reassign benefits if Medicare is across the board required in every setting? And when do they actually notify folks of this requirement?

 

[Peacemaker36]

My understanding is that once you enroll in Medicare in any capacity (solo, hospital, group practice, etc) you are henceforth THEIRS and you cannot decline Medicare no matter where you practice. Unfortunately, if you work at any other practice locations, you still need to get credentialed there in order to bill. So, yes, it is possible that you could be a Medicare provider yet still have no way of seeing patients in another location: you can't bill Medicare and you can't not bill Medicare.

Can't wait to see how Medicare for all plays out...

I'd love to be wrong on this, so let me know if you have heard differently from APA or Medicare.

 

[foreverbull]

My understanding is that once you enroll in Medicare in any capacity (solo, hospital, group practice, etc) you are henceforth THEIRS and you cannot decline Medicare no matter where you practice. Unfortunately, if you work at any other practice locations, you still need to get credentialed there in order to bill. So, yes, it is possible that you could be a Medicare provider yet still have no way of seeing patients in another location: you can't bill Medicare and you can't not bill Medicare.

Can't wait to see how Medicare for all plays out...

I'd love to be wrong on this, so let me know if you have heard differently from APA or Medicare.

It turns out you're correct.

Per a Noridian representative: if you are credentialed in one setting in Medicare, if wanting to charge private pay at the 2nd, you MUST opt-out at the 2nd setting (I guess enroll your business but then opt-out?), otherwise it is fraud to take Medicare-insured clients in the 2nd setting and charge private pay (without notifying Medicare that you work in the 2nd setting with potential Medicare plan clients).

The rep said that if you don't opt-out, but a Medicare client tries to get reimbursement after seeing you, Medicare would find out and you'd be committing fraud. I think the fraudulent act is accepting Medicare-insured clients at all without them knowing you take Medicare in another setting (and not opting-out at PP). If Medicare ever found out, you'd be in trouble.

To stay on the safe side, the key is to enroll the PP business but "opt-out" of participation in Medicare in PP. Or you'd have to flat out refuse to take ANY Medicare-insured clients in private practice if you don't opt-out.

I reviewed my old contracts/signed forms and none stipulated that you're required to accept Medicare at every setting once you opt-in/enroll (the language reflected only the site you're practicing at). I wish this was clearly stated upon enrollment, but it isn't, so this is an important warning for practitioners working part-time in other clinical settings who are credentialed/enrolled in Medicare.

 

[Sendtrees]

This is my situation. By far the easiest thing to do would be to incorporate myself in my private practice and have a separate NPI, but that is not actually necessary. I have a letter that explains that my PP and my job are completely independent, that I don't see people at both locations simultaneously, and that I am not paid directly by any insurance companies (the organization is, and I get paid a salary). I give this letter to people when they submit for OON benefits in my PP and it works well enough--they get paid. The only thing is, I don't want to mess around with Medicare because I think people are correct that you can't opt out once you're in, so I only see Medicare folks in one location, where they can use it. Another annoying thing is that people call me on my PP number all the time, since it is the number associated with my NPI, and they think I take their insurance. So I have to screen more calls from people who can't see me in PP. But that doesn't feel like such a big deal to me.