Yesterday I spoke to a podiatrist who is currently starting a house calls practice. He is trying to maintain a more conventional practice to keep a steady income while he builds his house call based practice. He had a couple of great questions:
Keep in mind that I am not a healthcare attorney and I'm not actually a business advisor. I am just a podiatrist who started doing house calls and makes a great living doing so. But here is my understanding of the rules after having discussed these exact questions with my own healthcare attorney years ago.
1. Can I accept Medicare and bill Medicare for the patients I see in the nursing home, and then when a patient with Medicare has emergency and needs to have an ingrown toenail removed at home can I see them and have the patient pay me cash for the house call?
No. Either you accept Medicare and you are a Medicare provider, or not. If you want to opt out of Medicare you have to follow a specific formal process to get out of the Medicare system. I used a healthcare attorney to help facilitate that process. I now send a renewal to Medicare in order to confirm that I continue to be "opted-out" every two years.
Any services provided to a Medicare patient by a Medicare provider must be billed directly to Medicare....never, ever to the patient.
However, if you "opt-out" of Medicare you're no longer a Medicare provider. You are then free to charge patients directly. This is what I do. I charge whatever fee I want. Currently $300 for a new patient evaluation. The patient pays the fee to me, right then. My service is completely unrelated to Medicare at that point...because I am no longer a Medicare provider. But be to be clear, I have had the patient sign a Medicare Opt-Out Agreement so that I have a record that they understand I am no longer a Medicare provider. This also is a requirement of Medicare.
There are huge fines and penalties for doctors who bill Medicare patients directly (if they are are still in the system as a Medicare Provider). My solution, as you might have guessed, is to opt out and refuse to participate in the Medicare system.
2. Can I have a patient sign a form understanding and acknowledging that they know I'm not going to bill Medicare...and that we both agree that they're going to pay me in cash? Is this legal?
No. As mentioned above is illegal to bill a patient for services that you provide if you are still in the Medicare system as a Medicare Provider. You must opt out and stop becoming a Medicare Provider if you're going to bill patients directly. The Opt-Out Agreement is only a specie form (signed by you and the patient) to inform patients that you used to be a Medicare Provider, but that you are no longer a Medicare Provider...basically that you quit working with Medicare. The patient then understands that you are not going to bill Medicare, they cannot bill Medicare, and none of your services are ever going to be reimbursable by Medicare.
3. Can I opt out of Medicare and then also work under another doctor's Medicare number to see patients in the nursing home?
No. But I have heard from lots of doctors that they do it anyway. It is a very common arrangement where a new physician out of school will see patients working with another physician. Many doctors believe that this is a gray area. The doctor without a Medicare number treats a patient. The doctor with the Medicare number cosigns the note and bills Medicare. It seems like this is reasonable and should be legal.
I did discuss this with a healthcare attorney. I paid thousands of dollars for their team to research this and determine whether or not it was reasonable. In the end they said that it was more than a "gray area" in fact it would likely be ruled is downright illegal if ever tested in court. If you were to do this you could wind up paying large fines to Medicare.
To me, this just seems far too risky given the small amount of money that you can actually make the Medicare patients under another doctors Medicare number. This certainly exceeds my personal tolerance for risk.
4. Can't I just get a separate office address and separate business license so that one is a Medicare location and one isn't?
This also seems like it should be completely reasonable. However, as explained above, it is the doctor that is the Medicare provider not the office location. This question actually came from an anesthesiologist when I was in the operating room recently. She was asking me whether or not she could start up a concierge-type chronic pain practice on the side to make some extras cash.
Because she is an anesthesiologist and has to see patients in the hospital, a large portion of her patients are Medicare patients. Her anesthesia group of course bills Medicare. That being the case, she has to accept Medicare and bill Medicare for those patients.
Her thought was that she would set up a separate business that was different than her anesthesia practice which would only focus on chronic pain medicine, and where she would bill patients directly for services provided at home. Again, this seems like it would be totally reasonable however appears to be illegal.
With Medicare, it's really very simple...either you're in or you're out.
Dr. Christopher Segler is a successful podiatrist who only does house calls. He practices in the San Francisco Bay area. He has recently written a book teaching other doctors how to set up housecalls-based practice that is more profitable and avoids all the administrative hassles associated with insurance companies and Medicare.
