Thursday, February 16, 2012

Firing All Patients With Medicare

When I announced on my favorite physician Web board that I had mailed discharge letters to five patients solely because they have Medicare my colleagues hailed me as their "hero."

I don't feel like a hero.

I opted out of Medicare years ago, but Medicare requires physicians who have opted out to write a letter reaffirming that status every two years. Last year I realized it might have been four years, so I dashed off a letter and waited. You can imagine my shock when, on February 10, 2012, I opened a letter from "Darla" (no signature or last name) dated August 4, 2011, but with no postmark on the envelope. Darla writes that my "affidavit does not meet CMS requirements." (What affidavit?) She goes on in her 6th grade English: "Opt Out Affidavit was unable to be processed. We did not receive the requested information in a timely manner. A request for information was sent June 13, 2011 to apply for a Type 1 NPI number." (If Darla intends to say Noridian, the Medicare administrator for my area, sent that information to me, I never received it, and I already have some type of NPI number.) Then she writes that I need to use my "Legal Name" when "filling out the information." (How does one "fill out information?")

I called Noridian provider enrollment to investigate. "April" reminded me that treating these Medicare beneficiaries without opting out subjects me to prosecution. I don't want to go to jail, although at least there I might have a right to free medical care.

I sent discharge letters to 5 patients and asked my office manager to call them to warn them in advance. Now I am completing a Medicare DISenrollment form. In the future I will require all new patients to demonstrate that they do NOT have Medicare.


  1. More like a heel than a hero if what you did is as you described.

    Sending a letter without prior warning, not terminating with patients in person including solid referrals for continuity of care and a plan of care during the transition is plain old patient abandonment. But you know that.

  2. perishedcore, if I met with them in person I would have been breaking a stupid law. And just who should I refer to when nobody else wants Medicare patients?

  3. And then, as I understand it, you'll have to drop your existing patients before they start collecting social security. It's complicated but, in general, we can't get social security at retirement unless we sign up for Medicare.


  4. Sadly Jackie you are correct. Except I learned just in the past few days that I can "private contract" so to speak with a patient who has Medicare Part A but not Part B.

  5. Actually, the "breaking the law" argument isn't really valid here.

    Even if you haven't opted out correctly, you can meet with your Medicare patients in person to talk with them or treat them, as long as you don't bill Medicare or charge the patient. Or you could see them as a non-participating Medicare provider (meaning you have the patient pay you and let Medicare repay the patient, instead of accepting Medicare payments directly yourself), bill them the maximum allowed amount by law for a Medicare patient, and submit a statement to Medicare with the correct provider number so the patient can get reimbursed, but whether you want to go through all that bother is up to you. Either way, it's perfectly legal. Yes, you'll lose some money, but you admit you didn't follow the rules about opting out of Medicare every two years to begin with, which isn't your patients' fault.

    But even if you don't think it's your fault either, or that it's unkind to have the office manager call them and terminate treatment by letter, your Medical Board would have something to say about it. You are professionally obligated not to abandon them, which means you need to continue to treat them until they have had a reasonable time to find another provider, which is usually 30 days. Also, you do have to give them referral information. You're not required to find them a psychiatrist who takes Medicare, but you are required to give them reasonable information regarding how they can continue their psychiatric treatment, e.g. a referral to a private psychiatrist like you who doesn't take Medicare, even if the patient would prefer to use Medicare, or if they can't afford to pay out of pocket, to a clinic that takes Medicare or provides low-cost care.

    With regard to "private contracts" -- that's what you've been doing all along, charging patients whatever they agree to pay. When you opt out, you can see any Medicare patient you want, and charge whatever you want. The only issue is that Medicare won't reimburse a single penny to the patient; it's all-or-nothing.

    Might I suggest taking a one-day course on the topic of billing, insurance, and Medicare? That's how many of us learned how it all works, and it's actually important to know a lot of it even if your entire practice is private-pay.

  6. I have to disagree anon. My understanding of the law is that if you have not opted out you MUST bill Medicare unless it "not a covered service." If you have opted out, you must NOT bill Medicare.

    This isn't about finding "fault." Medicare patients are the victims of bad policy. My letter did give 30 days notice and adequate referral information. Fortunately all the patients are stable and don't really need visits. Physicians still are ethically allowed to choose whom to treat and whom not to treat.

    If I take a course it will be on a clinical topic. I have no ambition to become an expert on getting money for patients.