Tough Hard Decision: What To Do About Medicare

It seems both ironic and inevitable: I won’t be getting any more “meaningful use” checks. It’s not that I didn’t qualify for the money; I saw plenty of patients on Medicare and met all of the requirements. I was paid for my first year money without much hassle. The problem I am facing is this: I am probably going to be “opting out” of Medicare, and once I do that I will cease to exist as far as HHS is concerned, and they are the ones who write the “meaningful use” checks. No existence equals no money.

This is ironic because I have gotten famous for how well I’ve used electronic medical records, have written advice for physicians trying to qualify for “meaningful use,” and am esteemed enough to be often asked for my opinion on the subject (culminating in a presentation last year for CDC public health Grand Rounds).  I have spent much of the past 16 years disproving the myths that small practices couldn’t afford EMR, that EMR decreases profitability, or that they reduce quality of care.  We not only could afford EMR, we flourished, using it as a tool to increase both productivity and profitability.  Not to overstate the issue, but my practice (and others like it) paved the way for the existence of “meaningful use.”  I don’t know if that’s a good or a bad thing.

But, as fate would have it, I am leaving the practice in which I did all of this work and am starting a new practice with a different payment system.  Instead of charging for office visits or tests done in my office, I am charging a monthly “subscription” fee for access to my care and to the other resources I offer.  But there isn’t a Medicare code for a monthly subscription fee, and the rules of Medicare are such that, as far as I can tell, I cannot have the practice I intend to build and be listed as a Medicare provider.  This is the case even if I never charge Medicare for any of my services.

Regarding my status as a Medicare provider, there are three options:

  1. Accept Medicare as a “participating” provider – This means that I see Medicare patients and accept what they say I will be paid.  I bill CMS for my services, which are based on my “procedure codes.”  My main procedure is the office visit, but I can also bill for things like immunizations, lab tests, and office procedures.  The more procedures I bill for, the more I get paid, but I must justify this billing in my documentation or run the risk of being accused of fraud.
  2. Become a “non-Participating” Medicare provider – In this scenario, I am paid by the patient for the encounter and then they are reimbursed for what they paid me.  The choice of what I bill happens the same way, and I still must set fees based on what CMS tells me (although I can bill a little bit more than I would if I was a participating provider).  Billing is, once again, based on the documentation of the visit.
  3. “Opt out” of Medicare altogether – Opting out means that I am no longer in the Medicare database as a provider and won’t get paid by them at all.  Patients are free to come to me, but they must pay what I charge, and I set my fees based on what I think is best.

So why does this matter if I am not planning to send any charges to Medicare?  Why do they care if I charge a monthly fee for my services if patients agree to do this outside of Medicare’s coverage?  By becoming a provider for Medicare (participating or not) I agree to accept their payment for my services.  The exception to this is for services that are not normally covered by Medicare, for which (with the proper waiver signed by my patients) I can charge what I want.  Cosmetic surgery is a good example (and one for which many Florida plastic surgeons are thankful) where the patient may opt to pay out of pocket for non-covered services.  Many of my services would actually fall under non-covered status, including electronic visits, my help with the PHR, annual care plan review, and the premium education content I will include on my website.  But since my Medicare patients will be able to receive care that is normally reimbursed (office visits, lab tests), the monthly subscription could be seen as accepting payment for these services outside of the agreed-upon Medicare rate.

As an “opted out” provider, I can see Medicare patients as long as they have signed a contract with me that meets Medicare’s requirements.  Since this will be the case with all of my patients, it should be no problem seeing Medicare patients in my office.  Unfortunately, opting out of Medicare has some pretty major downsides:

  1. I could only see Medicare patients who have signed a contract with my practice.  This means that I could not work in an ER or a prompt care to supplement my income (unless I figured out a way to see only non-medicare patients).  It takes away a pretty big financial “safety net.”
  2. I would be unable to get back to provider status for two years.  The mandatory opt-out period is for two years (so physicians don’t go on and off of Medicare frequently).  Again, this raises the stakes for me, as I can’t just go back to the old way if this practice doesn’t succeed.
  3. Many of my Medicare patients would think they couldn’t keep me as their doctor.

Giving up the $12,000 check for “meaningful use” is a minor consideration compared with these two things.

So why not stay in Medicare?  Let me count the ways:

  1. I have to bill for care.  Simplicity is one of the cornerstones of a direct-care practice, while complexity is synonymous with medical billing.  I don’t want to have people owing me money, I want them to pay at the start of the month for everything.
  2. Billing for Medicare would also mean I’d have to bill all other patients for the same services, as I am not allowed to charge others less than I do for Medicare beneficiaries.
  3. I’d have to get (and pay for) a billing system.
  4. I’d have to hire staff to do the billing and collect on it.
  5. I’d have to write my notes to meet the requirements for payment (as opposed to writing them for better patient care).
  6. I’d have to submit my bills using the proper procedure codes, paired with the proper diagnosis codes, submitted in the proper format, sent to the proper vendor.
  7. I’d have to deal with denied claims and the appeals process.
  8. Failure to do any of this (either by intent or mistake) would leave me open to fraud charges (even if my doing so was to my own financial detriment).

So, I am left with the choice: accept the consequences of opting out, or stay in the world of codes, complexity, and the ever looming threat of fraud accusation.  But this isn’t the real choice for me; the real choice is a much easier one: who do I want to work for, the patient or the payor?

I guess it’s only fair that I put my future in the hands of my patients, since they’ve been trusting their futures to me for the past 18 years.

Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at More Musings (of a Distractible Kind)where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player.  He is a primary care physician.

15 replies »

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  3. Funny that you say you are not attacking concierge patient’s intelligence – and then you immediately attack their intelligence – “will not understand.”
    You must not understand that no concierge patient receives services until they have paid their bill – pretty difficult not to understand when you already purchased the service.
    There are Medicaid patients whose parents are employed and covered by their own non-Medicaid insurance. Why wouldn’t the parents want to have the whole family skip the lines and have access to their family doc via email/phone/guaranteed same day access? Have you even been to a clinic where Medicaid patients are receiving services? They are no where near as homogeneous as you seem to think – some of them pay monthly for data plans and for cable TV – why should they balk at paying for a premium service that is even more useful than cable TV? I don’t hear anyone calling for Medicaid patients to be forbidden to have a data plan on their phone – why shouldn’t they be allowed to have a premium plan to access the physician that they trust? Especially when all they have to do to pay for it is cancel their cable and get a set of rabbit ears.
    I for one don’t think Rob should have given you a pass on your tone.

  4. @Rob I don’t know where you get that I was attacking you or your patients intelligence. My point is that concierge services are really just about paying more for access – something that many people will not be able to afford and will likely not understand. Until a bill arrives.

    And you say that Medicaid patients are interested in Concierge services you provide? Seriously? And you think that’s a good thing? It they are Medicaid patients they have money to spend on Concierge services. Unreal.

    BTW, If you think that anyone who reads a blog post must read all of your previous blog posts to gain context and understanding about your blog post, then that seems rather presumptious of your readers. Maybe you could add a reference to previous posts that support what you think should be obvious to new readers?

  5. Why not incorporate your medical practice as a charity, get a 501(c)(3) IRS letter and raise funds to care for your patients by contribution as well as “selling” your services as a physician and medical director (for which you receive a salary). Create a governing board of like minded neighbors and patients. A significant amount of your vision is not for private gain but for public benefit, you are publicly reporting to your community. You are a community asset just become a philanthropy and seek contributions to sustain your practice community health approach. Offer training and workshops and you’ve fulfilled the education component. Go back to charitable roots of medicine and health care. There is paper work but a lot less.

  6. Obviously you are late to this, so I’ll overlook your tone. My readers know that I am going to this type of practice because “traditional” care wasn’t making me enough money, it is because I couldn’t give good enough care. All of these answers have been given at length in previous posts over the past few months. My patients know this is no substitute for insurance and that insurance won’t cover my monthly fee (which ranges from $30-60/month) because I’ve told them. Those who are waiting for the practice to reopen are following me on facebook (where my posts are re-posted), are getting my newsletter (where I spell this out) and many have asked me in person.

    Of interest, most of those who have expressed a definite interest in joining me are Medicare patients, and some are Medicaid patients. Those with no insurance (which numbered over 500 in my old practice) are thrilled by the prospect. Businesses have approached me with the possibility of pairing this with a high deductible plan and saving money.

    I find it interesting that you attack me because I do this, yet you seem to have a very low opinion of my patients’ intelligence. They are not dumb, and I don’t treat them as if they are. The support I am getting from my patients has been quite amazing, even from people who are not able to stay with me. I guess that’s because I took the time to explain things after listening to their questions (as any good doctor should). And that’s exactly what I’ve done to make sure they understand exactly what I am doing.

  7. The number of local docs (many of them much less outside-the-box thinkers than me) who have told me that they are ready to bolt if I can show it works has shocked me. It really shows the level of pessimism doctors feel about our system. It bears out the recent study that shows only 15% of primary care docs happy with the system, and I think it goes much deeper than that. It’s scary.

    What do you think the payors can do (specifically Medicare and Medicaid) to prevent this from happening? My greatest fear is that there will be a mass exodus which will result in the requirement that docs accept Medicare to be licensed. I’ve heard rumblings of this and it really scares me. I think you would then see docs leaving medicine altogether.

    This is part of the reason I feel the need to try to grow this back to the same patient numbers I had in my old practice (see my post on the “organic medical home”) through use of nurses, midlevels, social workers, and other allied health professionals. I don’t want lawmakers to get desperate, as it greatly increases the likelihood of them doing something very destructive.

  8. Don’t tell me. The Senate Finance Committee could fix this by putting in single payer??

  9. Not to mention ALL the other services that concierge docs will order (labs, imaging, rehab, yada, yada) that WON’T be covered by their monthly payment.

  10. “Concierge coverage” seems like a good solution for SOME docs. But I have some questions:

    1. How many can ‘afford’ to not participate with Medicare and Commercial Payers who require submission of claims?

    2. How many people will be able to participate in this type of ‘coverage’ when they realize they can’t get these monthly fees paid for by their carriers?

    3. How many people understand they’ll still need to have coverage for inpatient and catostrphofic events?

    4. Many other questions and concerns about this approach of “opting out.”

    While not having to ‘complex bill’ and being paid up front is certainly very attractive and very much “Doctor Nirvana” (Nirvana for all professions… for that matter) this Nirvana seems sorta naïve and not well thought out

  11. Between the docs going “off the grid” like Rob and those simply retiring, it’s going to take Medicare’s Congressional minders about five years to realize we’ve got an authentic physician access crisis on our hands, and they amend the program to make “subscription” payments Medicare-billable. And the boomers who enter Medicare in the next five years and their parents, if they are still living, that will pay the price. We’ll all have great big red “M’s” on our foreheads.

    After making it “reimbursable”, of course, they’ll pile on the core measures until it’s just as unprofitable as the fee-based system that is driving the Dr. Robs away. God love ’em. We just can’t do “simple” in the Medicare program to save our lives . . .