Coding Cues: Medicare provider obligations

Key Points

I'm employed by a large group practice in a resort community that participates in Medicare. Because of our size, our call rotation allows significant free time, and several resort owners have asked me to provide weekend and evening care to vacationers after my normal practice hours. They've offered to keep my contact information at their front desks and inform anyone who wishes to use my services that I take cash only and will not bill third-party payers. They also suggested that I set my fees to "adequately compensate" me for being on call. Am I correct in suspecting that this is too good to be true?

Your instincts are right-for vacationers covered by insurance. As a Medicare provider, you are obligated to (a) accept the allowed amount for Medicare-covered services if you are a participating provider or (b) bill no more than the limiting charge for those services if you are a nonparticipating provider. In both cases, you must file the claim for the patient.

To charge what you wish, you may "opt out" of the Medicare program (See "Coding Cues," Jan. 18, 2008, for details); but, if you do, you cannot remain a provider in your group, since Medicare can't reimburse a physician-either directly or indirectly-who has made that election. (Indirect compensation is that which goes to the group and, by virtue of an income distribution formula, flows to the opt-out provider.) You would, however, be free to set your own fees for vacationers who are not in Medicare, as long as the terms of any commercial contracts your group practice has are not violated as a result.

The author, vice president of operations for Reed Medical Systems in Monroe, MI, has more than 30 years' experience as a practice management consultant, as well as being a certified coding specialist, certified compliance officer, and a certified medical assistant.