Bioethics Discussion Blog: U.S. Doctors: Getting Paid the Old Way-- by the Patient

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Sunday, November 23, 2008

U.S. Doctors: Getting Paid the Old Way-- by the Patient



Dr.S.Smiley Thakur writing in the November 21, 2008 Seattle Post Intelligencer sets the tone for the column titled "Why Doctors Can't See You Now" with:

Physicians have been keeping a secret from you: The practice of medicine simply isn't a viable business. This reality affects not only the availability of doctors to care for patients, but also the quality of delivered care. After 10 years in full-time clinical practice, I decided to stop accepting Medicare and all private insurance. Such a move seems illogical to physicians and patients, but was made to preserve patient access to quality care. Physicians who don't come to the same conclusion risk going out of business.

Read the column and then come back and let us know your opinion, whether you think that Dr. Thakur is on the right track regarding the facts and consequences or that government and insurance companies should continue to play a role in the financing of medical care and the doctors should continue to participate with these systems.

Do you think that doctors should go back to the old days where each patient was responsible to pay the doctor out of his or her pocket and the doctor was beholding to nobody except the patient? ..Maurice.

Graphic: Digital photograph by my wife 11-24-2008.

11 Comments:

At Monday, November 24, 2008 4:27:00 PM, Blogger Joel Sherman said...

Dr Smiley doesn't break new ground. His solution isn't practical for the vast majority of physicians who aren't in very affluent areas with patients who can afford boutique practices. If I refused insurance payments, my practice which is probably over half Medicare now would be devastated.
But the pressure on physicians and society is certainly getting worse every year. My guess is that socialized medicine is inevitable with all of us paying higher taxes to pay for it. I don't look forward to it, but I doubt that it would be worse than the chaos we have now.

 
At Monday, November 24, 2008 8:40:00 PM, Blogger Maurice Bernstein, M.D. said...

To add to this discussion, here is a current press release from the Physicians' Foundation. Go to the link to find more about the organization but also download the complete survey data. ..Maurice.

November 18, 2008

BOSTON–A survey released today by The Physicians’ Foundation depicts widespread frustration and concern among primary care physicians nationwide, which could lead to a dramatic decrease in practicing doctors in the near future. The survey examined the causes behind the doctors’ dissatisfaction, the state of their practices and the future of care. The resulting findings show the possibility of significantly decreased access for Americans in the years ahead, as many doctors are forced to reduce the number of patients they see or quit the practice of medicine outright.

An overwhelming majority – 78 percent – of physicians believe that there is an existing shortage of primary care doctors in the United States today. Additionally, nearly half of them – 49 percent, or more than 150,000 practicing doctors– say that over the next three years they plan to reduce the number of patients they see or stop practicing entirely.

“Going into this project we generally knew about the shortage of physicians; what we didn’t know is how much worse it could get over the next few years,” said Lou Goodman, PhD, President, The Physicians’ Foundation. “The bottom line is that the person you’ve known as your family doctor could be getting ready to disappear – and there might not be a replacement.”

The Physicians’ Foundation believes the future of primary care could have a significant impact on the American healthcare debate.

“At a time when the new Administration and new Congress are talking about ways to expand access to healthcare, the harsh reality is that there might not be enough doctors to handle the increased number of people who might want to see them if they get health insurance,” said Walker Ray, MD, Vice President, The Physicians’ Foundation. “It’s as if we’re talking about expanding access to higher education without having enough professors to handle the influx of students. It’s basic supply and demand.”

The reported reasons for the widespread frustration among physicians include increased time dealing with non-clinical paperwork, difficulty receiving reimbursement and burdensome government regulations. Physicians say these issues keep them from the most satisfying aspect of their job: patient relationships.

“Tens of thousands of primary care doctors face the same problems as millions of ordinary citizens: frustrations in dealing with HMOs and government red tape,” said Sandra Johnson, Board Member, The Physicians’ Foundation. “The thing we heard over and over again from the physicians was that they’re unhappy they can’t spend more time with their patients, which is why they went into primary care in the first place.”

 
At Tuesday, November 25, 2008 12:17:00 AM, Anonymous Emily said...

I can understand a doctor's frustration with delayed or inadequate reimbursement from medicare. But, if I agree to pay his fee in total up front, can I then on my own take those bills and apply for reimbursement for whatever medicare allows? Or does the doctor's withdrawal from the system negate my rights to do so?

 
At Tuesday, November 25, 2008 7:35:00 AM, Blogger Maurice Bernstein, M.D. said...

Emily, to my knowledge, if a doctor doesn't accept Medicare, Medicare doesn't accept the doctor's charges to you and won't reimburse you. ..Maurice.

 
At Tuesday, November 25, 2008 7:44:00 AM, Blogger Joel Sherman said...

I think you are wrong Dr B. I'm pretty sure that Medicare will then reimburse to the patient what they allow.

 
At Tuesday, November 25, 2008 11:05:00 AM, Blogger Maurice Bernstein, M.D. said...

Joel, I think I'm right. Here is a protocol from the Association of American Physicians and Surgeons. The opting out is based on agreement with both the government and the patient. Remember, for a physician to opt out means the physician does not want to deal with Medicare, including submitting diagnosis and service charge documents to the government. Now whether this decision is ethical and professional, that is another matter. ..Maurice.


1601 N. Tucson Blvd. Suite 9
Tucson, AZ 85716-3450
Phone: (800) 635-1196
Hotline: (800) 419-4777
Association of American Physicians and Surgeons, Inc.
A Voice for Private Physicians Since 1943
Omnia pro aegroto

HOW TO OPT OUT OF MEDICARE

It is simple to opt out of Medicare - far simpler than staying in the Medicare program. Hundreds of physicians have already opted out, and we not heard a single regret by any of these physicians. Once CMS unleashes its dreaded new program of "private auditors" to shake down physicians in the Medicare program, far more physicians will likely opt out - and even more will wish they had.

We have prepared this "How To" guide for your benefit. These suggestions do not constitute legal advice - please consult an attorney for any legal issues or questions.

IF YOU ARE A NON-PARTICIPATING PHYSICIAN, then opting out is as follows:

Step One: Notify your patients that you are opting out of Medicare.

Step Two: File a copy of the following affidavit with "each carrier that has jurisdiction over the claims that the physician or practitioner would otherwise file with Medicare." (quoting CMS Qs and As on Private Contracts, #10). The addresses will vary depending on the region of the country in which you practice. Click here for a list of Medicare carriers by state. The affidavit should be equivalent to the following:

I, ______, declare under penalty of perjury that the following is true and correct to the best of my knowledge, information, and belief:

1. I am a physician licensed to practice medicine in the state of ______. My address is at _________, my telephone number is _________, and my [national provider identifier (NPI) or billing number, if one has been assigned, uniform provider identification number (UPIN) if one has been assigned, or, if neither an NPI nor a UPIN has been assigned, my tax identification number (TIN)] is _________. I promise that, for a period of two years beginning on the date that this affidavit is signed (the "Opt-Out Period"), I will be bound by the terms of both this affidavit and the private contracts that I enter into pursuant to this affidavit. [NOTE: Your personal UPIN number must be used, not a corporate UPIN number. Persons opt out, not corporations.]

2. I have entered or intend to enter into a private contract with a patient who is a beneficiary of Medicare ("Medicare Beneficiary") pursuant to Section 4507 of the Balanced Budget Act of 1997 for the provision of medical services covered by Medicare Part B. Regardless of any payment arrangements I may make, this affidavit applies to all Medicare-covered items and services that I furnish to Medicare Beneficiaries during the Opt-Out period, except for emergency or urgent care services furnished to Beneficiaries with whom I had not previously privately contracted. I will not ask a Medicare Beneficiary who has not entered into a private contract and who requires emergency or urgent care services to enter into a private contract with respect to receiving such services, and I will comply with 42 C.F.R. § 405.440 for such services.

3. I hereby confirm that I will not submit, nor permit any entity acting on my behalf to submit, a claim to Medicare for any Medicare Part B item or service provided to any Medicare Beneficiary during the Opt-Out Period, except for items or services provided in an emergency or urgent care situation for which I am required to submit a claim under Medicare on behalf of a Medicare Beneficiary, and I will provide Medicare-covered services to Medicare Beneficiaries only through private contracts that satisfy 42 C.F.R. § 405.415 for such services.

4. I hereby confirm that I will not receive any direct or indirect Medicare payment for Medicare Part B items or services that I furnish to Medicare Beneficiaries with whom I have privately contracted, whether as an individual, an employee of an organization, a partner in a partnership, under a reassignment of benefits, or as payment for a service furnished to a Medicare Beneficiary under a Medicare+Choice plan, during the Opt-Out Period, except for items or services provided in an emergency or urgent care situation. I acknowledge that, during the Opt-Out Period, my services are not covered under Medicare Part B and that no Medicare Part B payment may be made to any entity for my services, directly or on a capitated basis, except for items or services provided in an emergency or urgent care situation.

5. A copy of this affidavit is being filed with [the name of each local Medicare carrier], the designated agent of the Secretary of the Department of Health and Human Services, no later than 10 days after the first contract to which this affidavit applies is entered into. [FOR PARTICIPATING PHYSICIANS ONLY: My Medicare Part B Participation agreement terminates on the effective date of this affidavit.]

Executed on [date] by [Physician name]
[Physician signature]

Step Three: Enter into a private contract for, and prior to, rendering any covered services to a Medicare Part B Beneficiary. Such private contract should include the following:

This agreement is between Dr. __________ ("Physician"), whose principal place of business is _____________, and patient ____________ ("Patient"), who resides at __________ and is a Medicare Part B beneficiary seeking services covered under Medicare Part B pursuant to Section 4507 of the Balanced Budget Act of 1997. The Physician has informed Patient that Physician has opted out of the Medicare program effective on _____ for a period of at least two years, and is not excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 or any other section of the Social Security Act.

Physician agrees to provide the following medical services to Patient (the "Services"):

[LIST ALL THE SERVICES HERE]

In exchange for the Services, the Patient agrees to make payments to Physician pursuant to the Attached Fee Schedule. Patient also agrees, understands and expressly acknowledges the following:

* Patient agrees not to submit a claim (or to request that Physician submit a claim) to the Medicare program with respect to the Services, even if covered by Medicare Part B.

* Patient is not currently in an emergency or urgent health care situation.

* Patient acknowledges that neither Medicare's fee limitations nor any other Medicare reimbursement regulations apply to charges for the Services.

* Patient acknowledges that Medi-Gap plans will not provide payment or reimbursement for the Services because payment is not made under the Medicare program, and other supplemental insurance plans may likewise deny reimbursement.

* Patient acknowledges that he has a right, as a Medicare beneficiary, to obtain Medicare-covered items and services from physicians and practitioners who have not opted-out of Medicare, and that the patient is not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted-out.

* Patient agrees to be responsible, whether through insurance or otherwise, to make payment in full for the Services, and acknowledges that Physician will not submit a Medicare claim for the Services and that no Medicare reimbursement will be provided.

* Patient understands that Medicare payment will not be made for any items or services furnished by the physician that would have otherwise been covered by Medicare if there were no private contract and a proper Medicare claim were submitted.

* Patient acknowledges that a copy of this contract has been made available to him.

[Optional:
* Patient agrees to reimburse Physician for any costs and reasonable attorneys' fees that result from violation of this Agreement by Patient or his beneficiaries.]

Executed on [date] by [Patient name] and [Physician name]

[Patient signature] [Physician signature]

[NOTE to physicians: keep a copy of all of these contracts in case CMS demands them! CMS requires that this contract be re-executed each period.]

Step Four: Install procedures to ensure that your office never files a Medicare claim, and never provides information to a patient that enables him to file a Medicare claim. The two exceptions - for emergency or urgent care and for covered services that Medicare would deem unnecessary - should be used with caution.

Step Five: Reduce the substantial overhead costs resultant from participating in the Medicare program and being subjected to the Medicare-inspired audits and threats. Then celebrate: you can now spend your time serving patients rather than catering to and being controlled by the government.

Step Six: Mark your calendar to send in a new "opt out" affidavit every two years to maintain your status.

IF YOU ARE A PARTICIPATING PHYSICIAN, then opting out is as follows:

Step One: In the words of CMS: "To opt out of Medicare, a participating physician must first terminate his or her Medicare Part B participation agreement." (CMS Qs and As on Private Contracts, #5). At the beginning of 1998, CMS only allowed termination of participation on an annual basis. More recently, however, CMS has allowed termination on the following quarterly basis: Jan. 1, Apr. 1, July 1, and Oct. 1. Note, however, that a participating physician must give his or her carrier 30-days' prior notice by sending in the opt-out affidavit with an effective date of the beginning of the next quarter.

Subsequent Steps: Follow the above Steps One through Five for a non-participating physician, except that the physician may not provide private contracting services until the first date of the next quarter that is at least 30 days after receipt of the notice by the carrier. For example, the carrier must receive the notice from the physician by Sept. 1 if the physician seeks to provide private contracting services beginning on Oct. 1. Mark your calendar to send in a new "opt out" affidavit every two years to maintain your status.

 
At Tuesday, November 25, 2008 11:28:00 AM, Blogger Joel Sherman said...

Dr B, that article is confusing, but when it says no payment will be made, it means to the physician.
Here is what Medicare itself says:
Non-participating physicians choose on a claim-by-claim basis whether or not to accept assignment. If the non-participating physician doesn’t accept assignment, Medicare pays you directly and the non-participating physician may bill you up to the limiting charge. If you go to a non-participating physician, it will probably cost you more.

 
At Tuesday, November 25, 2008 1:13:00 PM, Blogger Maurice Bernstein, M.D. said...

Joel, obviously if the following is a legal statement on the part of the physician's agreement with the patient then there is no federal requirement that all physicians who have formally opted-out are required to submit claim or document to the government describing the patient service. ..Maurice.

* Patient agrees not to submit a claim (or to request that Physician submit a claim) to the Medicare program with respect to the Services, even if covered by Medicare Part B.

 
At Tuesday, November 25, 2008 1:35:00 PM, Blogger Joel Sherman said...

What you post is a suggested protocol published by the association, not a law. I have no idea if any physician actually uses it. What would be the point of asking the patient not to submit the charges on their own when Medicare clearly says it is legal and would pay it?
But I don't know any physician who refuses Medicare, so I have no practical info on the subject. Free magazines such as Medical Economics have I believe certainly suggested that when a physician opts out, the patient can on their own submit a bill to Medicare.

 
At Tuesday, November 25, 2008 6:29:00 PM, Blogger Maurice Bernstein, M.D. said...

Joel, I think what is confusing the discussion here is understanding the various status that a physician can accept. The law is well explained in the American Medical Associations "Medicare Participation Options for Physicians" at this URL link:

http://www.aahcp.org/medicare_participation_options_update_062708.pdf

What is important to know is that there are the 3 options:
1) The physician signs up as a PAR and receives Medicare allowed payment in full for all Medicare patients. 2) The physician signs up to be a Non-PAR and the doctor is permitted to receive a Medicare allowed payment only for those Medicare patients for which the physician desires. 3) Become a private contracting physician (opt-out)billing the patients directly and forgoing any payments from Medicare to their patients or themselves.

It is all detailed in that link. Now here is what the patient needs to know, as detailed in the example contract (from the AMA link):

Beneficiary Obligations The beneficiary, or his or her legal representative, accepts full responsibility for payment of the physician's charge for all services furnished by the physician.
The beneficiary, or his or her legal representative, understands that no payment will be provided by Medicare for items or services furnished by the physician that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted.
The beneficiary, or his or her legal representative, understands that Medicare limits do not apply to what the physician may charge for items or services furnished by the physician. The beneficiary, or his or her legal representative, agrees not to submit a claim, nor ask the physician to submit a claim, to Medicare for Medicare items or services, even if such items or services are otherwise covered by Medicare.
The beneficiary acknowledges that this written private contract contains sufficiently large print to ensure that the beneficiary is able to read this contract.
The beneficiary, or his or her legal representative, has entered into this contract with the knowledge that he or she has the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted-out of Medicare and for whom payment would be made by Medicare for their covered services, and that the beneficiary has not been compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted-out. The beneficiary, or his or her legal representative, understands that Medigap plans do not, and other supplemental plans may elect not to, make payments for items and services not paid for by Medicare. The beneficiary, or his or her legal representative, understands that this agreement shall not be entered into with the physician during a time when the beneficiary requires emergency care services or urgent care services, except that the physician may furnish emergency or urgent care services to a Medicare beneficiary in accordance with 42 C.F.R. § 405.440.
The beneficiary, or his or her legal representative, acknowledges that a copy of this contract has been provided to the beneficiary, or to his or her legal representative, before items or services have been furnished to the beneficiary under the terms of this contract.


Thus, it is clear that for any Medicare patient, exclusive of within an emergency, who accepts a relationship with an opt-out physician whether they were PAR or non-PAR previously, must pay for the services of their physician out of their own pocket and not expect Medicare to reimburse them for that service.

Now.. back to the original question:
Do you think that doctors should go back to the old days where each patient was responsible to pay the doctor out of his or her pocket and the doctor was beholding to nobody except the patient? Specifically, would the medical attention and the medical care given to the patient be any better? ..Maurice.

 
At Tuesday, December 02, 2008 5:13:00 PM, Anonymous Anonymous said...

Yes, I think doctors are more responsible / responsive to patients when they are paying the bills. Less unnecessary tests & procedures when they must justify each cost.

 

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