Stung by rising medical malpractice insurance rates and declining reimbursements that have them working more and earning less, family physicians are looking for new sources of revenue. Some have responded by finding niche services to offer their patients. Others are simply finding ways to earn more for the work they’re already doing – by charging patients directly for services payers won’t reimburse them for.
Completing forms, responding to patients’ telephone calls, refilling their prescriptions and e-mailing with patients are just some of the services that family physicians are billing to patients – and getting paid for.
“My time and expertise are valuable, and if I don’t value it, no one else will,” says Anette Mnabhi, DO, a solo family physician in Montgomery, Ill., who has been charging patients for phone consults and various other services for more than a year.
Kathy Saradarian, MD, whose solo family practice is in Branchville, N.J., has a similar rationale for the fees she began billing patients for earlier this year. “I was staying hours after the office was closed, with staff, just responding to messages and requests. My medical opinion is my job; why was I giving it away for free? I just felt it was time that those patients creating the extra work and costs should start having to pay. No other professionals give it away for free involuntarily. And how many of my patients would stay late and work “off the books” for their boss?”
This approach is not without its risks. Billing patients for services they’re not accustomed to paying for is sure to strain doctor-patient relationships that are already stressed by payer-imposed requirements. On the AAFP’s practice management e-mail discussion list, where this is a frequent topic of conversation, family physicians worry that if they were to start charging patients for the extra services they provide, their patients might make life even more difficult than usual for their staff, or leave the practice, or complain to their health plans.
But physicians who charge for these services say that nearly all their patients have paid without question. For example, Alan Falkoff, MD, of Stamford, Conn., says 98 percent of his patients have accepted the policy he instituted in his four-provider practice in June 2003. Falkoff charges patients for a comprehensive list of services on an a la carte basis, as well as an annual administrative fee and a per-visit malpractice surcharge. (See “‘Extra fee’ models” for more information about each of these arrangements.)
Of course payers take a dim view of charging patients additional fees for services associated with covered benefits. The problem is that many of the services that physicians see as fair game are regarded by payers as “bundled,” or included with the payment made for other services, such as an office visit.
“You can always charge for a noncovered service, unless the health plan considers them to be bundled into a covered service – and this is sometimes moderately metaphysical,” says Alice Gosfield, JD, a health care attorney in Philadelphia and member of the FPM Panel of Consultants. For example, most health plans don’t pay for telephone calls, and they do not allow physicians to charge patients for such calls, because the plans consider payment for these calls to be bundled. Refilling prescriptions outside of an office visit is also often bundled, Gosfield says.
The same principle applies for Medicare, says William D. Rogers, MD, director of the Physicians Regulatory Issues Team at the Centers for Medicare and Medicaid Services (CMS). If the service is unrelated to a service that has been billed to Medicare, the physician may bill the patient. If the service relates to a service that has been billed to Medicare, payment is likely to be included in the practice expense for the primary procedure, so the physician should not bill the patient, Rogers says. “The practice expense component of the Medicare physician fee schedule reimburses physicians for administrative and overhead costs,” he says. In March, the Office of Inspector General for the Department of Health and Human Services issued an alert on concierge care that reminded doctors that physicians participating in Medicare “are subject to civil money penalties if they request payment for already covered services from Medicare patients other than the applicable deductible and coinsurance.” The alert cited a recent settlement with an internist who agreed to pay $53,400 to resolve his liability for violating his assignment agreement with Medicare by asking his patients to pay a yearly fee of $600 for services he said were not covered by Medicare. The services included “coordination of care with other providers,” “a comprehensive assessment and plan for optimum health and extra time spent on patient care.” The inspector general charged that many of the services included in the fee were in fact covered by Medicare.
The rules vary from payer to payer, however, and they can be hard to discern. Most health plan contracts don’t include a list of covered services, much less information about what services are bundled. The CPT manual provides some clues, but health plans aren’t bound to follow CPT to the letter, and many don’t.
Rogers suggests that where Medicare is concerned, physicians consider whether the service is one physicians have traditionally charged for. “If it’s not, then you probably shouldn’t charge patients for it without checking with the payer. It might be a bundled service,” he says.
The best way to determine whether you’re on solid ground is to call each health plan you contract with and ask about each service you’re interested in charging separately for. For information about Medicare, contact the carrier in your area. Get in touch with your state Medicaid agency to find out what you can charge separately for under the terms of Medicaid.
Coverage determinations will vary by payer and even across a single payer’s multiple plans, says Allan M. Korn, MD, senior vice president and chief medical officer for Blue Cross and Blue Shield Association in Chicago. “For services that aren’t governed by an agreement with an insurance company, that is, they’re not covered services or bundled, then certainly it might be appropriate for the physician to expect the patient to pay,” Korn says. He recommends that physicians contact their plans to find out what’s permissible.
Falkoff went a step further, hiring an attorney to review his contracts and determine whether the charges he now implements were a violation of his agreements with payers. They concluded that his contracts don’t prohibit it. “Most if not all of the plans either don’t want you to do this or are lukewarm about it,” Falkoff admits. Yet when a patient complained to one of the plans Falkoff contracts with, the plan told the patient that the charges were legal and not a violation of their contract.
Some physicians learn by trial and error what their payers will allow. Earlier this year, after implementing a charge for refilling prescriptions without an appointment, one physician received a letter from a Blue Cross Blue Shield plan telling him that doing so violated his contract. The letter encouraged him to have the patient come in so that an office visit could be billed. The charge for the office visit was significantly higher than his $5 prescription refill charge.
