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Medicare issues

Are there any docs that have not "opted-out" of Medicare/Medicaid but accept Medicare/Medicaid patients in their DPC practice? Until I build my practice to a sufficient number to pay the bills, I work part-time at the local family medicine residency program which requires me to participate in Medicare. Thus far I have excluded these patients from my practice. I don't want to go to jail. Problem is I have discovered some patients who do in fact have Medicare/Medicaid after they have signed up and signed the contract stating they don't. Additionally, I have some patients who will soon enter the Medicare age bracket and I don't want to lose those patients. Any suggestions? Ideas?


  • I have questions about this as well. I too will be working at an urgent care to pay the bills until it takes off. If I remember there was a discussion on this at the AAFP MIG DPC group. Here is Brian Forrest's response:

    "Ok- several comments floating around here about this issue. We have worked with a total of 5 attorneys on this issue that have special expertise in this area including national speaker experts from DPC meetings as you mention (I invited Jim to speak at the DPC Summit). Here are the key points based on the Thompson ruling of HHS several years ago which is the foundation for the ability to charge patients for non covered services.

    Option 1- Opt out of Medicare- then after this is in place- 90 days to be sure you can charge Medicare patients for whatever you want under a private contract you have with them. The details of what should be in that contract are on the CMS website. If you do this, then you nor patients that see you will bill anything to Medicare relative to your services.

    Option 2- If you do not want to opt out of Medicare, then you can still see patients that have Medicare as long as you NEVER charge them for anything that is a service that is covered by Medicare. You can charge them for what are called non covered services which is exactly what it sounds like. These are services that Medicare does not pay for- like "scheduling fees, advanced technology use fee, DPCMH (direct primary care medical home) fee, etc. So, if you were moonlighting in an ER and charging Medicare for Medicare covered services, but then charging patients for non covered services in your DPC practice that is OK.

    Even better- do both. A double layer of protection to insure you do not run afoul of these issues is to opt out of Medicare and still only charge for non covered services.

    All three have been done successfully by many people for years.

    I am not a lawyer- so I am not giving legal advice. But I am telling you what I have been telling hundreds of physicians over the last few years based on sound advice from legal experts in this area."
  • So, if I want to use option 2. Do I just put in my note that I am seeing this patient for direct primary care medical home and then talk about whatever their issues are? We don't put codes on anything and the invoices are generic, so where would this be evident?
  • Hi. Dr. Mike here (www.willowhealingcenter.com). I am opted in for medicare as I am doing procedures elsewhere which call for me to be opted in. as you know - you are either all in, or all out. So, you can't charge medicare patients a DPC/concierge/membership fee for MEDICARE COVERED SERVICES. So, the way I maintain my membership is charge my clients for an annual comprehensive physical exam (not covered by medicare and this isn't a wellness visit or welcome to medicare visit). My membership fees are $118/mo or $1436 per year. So the cost of the annual comp. physical exam is $1436 (prorated over 12 months to $118/mo). I fill out an ABN for this so they are aware. This way, my membership fees are covered as well as all concierge/DPC services that I offer. I do bill Medicare for services rendered (which are covered by medicare) such as 9921X or EKG etc. If they don't use a secondary insurance, they may be billed the remaining 20%. This 20% could possibly be written off if they have financial hardship. See your local medicare guidelines.
    I use Office Ally for my clearinghouse. It's free 100%. It takes me 2 minutes to submit (I input all my new medicare clients immediately and have a template for the CMS1500) so all I do is choose provider, my office location and the patient from a pull down, then enter ICD10 and charge). I can't believe how simple it is.
  • I practiced 17 years in a hospital owned FP office and left just over 3 years ago and am working for an employer based dpc. It has been great, but I am now contemplating opening up my own dpc to cater to individuals or very small businesses. I found out (either my former employer's negligence, my ignorance, or both) that my medicare was cancelled after I left, or a 'renew' later was not forwarded to me..details are not easily discoverable after hours of emailing and time on phones. I found this out when i tried to find out about opting out. So now the question is, do I just stay unenrolled, or do I re-enroll so that I can opt out? any experience or advice here?
  • Hi! Not enrolled or un-enrolled is different than opting out. You MUST opt out if you want to see medicare patients. If you see medicare patients and don't bill medicare, it's medicare fraud. Opt out formally and you're all set. Go online to your local medicare provider and download the paperwork. I would make a call and let them tell you just what you need. Hope that helps. Dr. Mike. www.willowhealingcenter.com
  • Dr Mike. thanks. I understand that un-enrolled is different than opting out. My position is that I AM un-enrolled. "Invisible" in the eyes of medicare. I can see medicare patients in a DPC clinic as long as I never bill medicare. but then if I ever want to order certain medical equipment or tests, I may not be able to do that(because I dont have a medicare number). So I am wondering if anyone out there has had this experience....would I be better to STAY un-enrolled and deal with those occasional frustrations, or go through the frustration of re-enrolling, and once I've done that, download the forms and THEN opt out. I know it's a confusing mess and I am not sure I am communicating this very well.
  • Drjms - we are medicare opt out and can still order medical equipment or tests even though we don't have a medicare number. Even when we order something that requires a prior-auth it still works. I have read that this might be changing but its still working for us in California. Mary-office manager-Wellcare MD, www.wellcaremd.com
  • I faced much the same issue because I was transitioning out of hospital medicine and into my startup DPC practice. I found the bottom line was this: you have to choose. Medicare does not allow any wiggle room. It can be very heart-rending to know you have to give up entirely something you love (for me, part time hospitalist work) in order to see Medicare patients in your clinic under the DPC model. But although sending in that affidavit was very hard for me, I have not looked back. My Medicare patients are the most rewarding patients I could possibly have. I think it's a question of getting to the fork in the road - you choose one direction because you can't choose both, but taking the road less traveled has wonderful rewards in the end.
  • I am going to opt out. I had read that it only has to be 30 days notice but what have others experienced? I am doing a geriatrics/palliative care home visit practice so will have nearly all medicare patients. In one of the posts on this string someone mentioned 90 days. Do they let you know when your request to opt out has been accepted or can you start seeing Medicare patients after a certain timeframe?
  • Here’s a great link from the CMS site that includes all the instructions on properly opting out of medicare > https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1311.pdf

    I would suggest reading it (only 6 pages) as it gives details on the specific info that needs to be included on the affidavit.

    CMS doesn’t have a standard form, however, many MAC’s (medicare administrative contractors) have forms on their website. That’s who you actually send the opt-out form to….the MAC in your jurisdiction.

    Here’s a map of the MAC’s > https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Who-are-the-MACs.html#MapsandLists

    One last opt-out tip…they typically ask for a 30 day notice of your opt out prior to the quarter you want the opt out to begin on.

    For example: if you want your opt-out to begin on July 1…you’d want to send the letter by June 1.
  • It depends on whether you are non-par or par with Medicare as to WHEN you can opt out. If non-par, it is effective the day you sign the affadavit!
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