Billing dilemmas with a concierge practice

Key Points

A: First, it is not necessary that you comply with your patient's request to attempt to file a claim with her primary insurer. You adequately notified the patient before accepting her into your concierge practice, and you gave the patient an opportunity to see another provider who accepted insurance so that the procedure would be covered.

That being said, clearly, you wish to assist your patient with obtaining reimbursement for the procedure you performed, if possible. You didn't indicate which insurers were involved, so I'll try to give you answers to multiple scenarios.

Once a provider is in the opt out status from the Medicare program, the provider's provider transaction access number, or PTAN, rather than his or her NPI, is deactivated, meaning the doctor's access number to file claims and receive payments no longer is active. Therefore, the physician can't file a claim electronically (for the reasons you stated previously).

Trailblazer, the MAC for Colorado, New Mexico, Oklahoma, Texas, and the Indian Health Service, states in Medicare Opt-Out Guidelines for Physicians/Practitioners that it will only allow submission of a claim by an opt out physician in an emergency using the GJ modifier indicating an "Opt out physician or practitioner emergency or urgent service." The service can only be rendered to a patient who is not contracted with that physician for medical care. If the physician provides an emergent or urgent service, the physician may not bill more than the limiting charge for that service-the same as a non-participating physician and must file the claim.

Highmark, the MAC for Maryland, Pennsylvania, the District of Columbia, Delaware, and New Jersey indicates the same instructions for its opt out physicians. The caveat if you are a Pennsylvania provider and are non-participating is that the Pennsylvania Health Practitioners Medicare Fee Control Act (Act 1990-91) prohibits you from billing more than the limiting charge.

With all of that said, the best course of action in trying to file a claim for your patient is to contact the MAC and inquire about how you might do that. We are aware of instances where a noncredentialed provider in a specialty that does not typically treat Medicare patients (such as a pediatrician or obstetrician/gynecologist) ended up with a Medicare patient under the circumstances you described previously. In those instances, both Trailblazer and Highmark had the provider submit a paper claim. The claim was treated as a nonparticipating provider claim, so the patient received a check for the limiting charge for the service, and the provider was required to write off the difference between the limiting charge and what the provider charged.

Commercial insurers' policies aren't quite as documented as those of Medicare. Some providers are treated as "out of network" providers if the provider is credentialed for other products through that insurer. The best course of action is to contact the insurer and determine how you might proceed.