Re: Need help. Working from within.

[Guest guest]

From Drain,

So I contacted my congressman's office, (Defazio) about finding a way to get a local exception to the regulation limiting the pricing of office visits to the medicare amounts, and forbidding us to have retainer practices for smaller amounts if we are also taking medicare. I put it to them that as of this week we have now had all the mills in Southern Oregon close, all the mines in Southern Oregon close, that 60% of my town's previously employed people are not now employed and that these uninsured are going to flood the single sliding scale federally funded clinic thirty miles away in Roseburg beyond capacity.

The congressman's office has agreed to help facilitate this, particularly aiming at underserved areas.

My memory is that there were one or two small exception practices that were allowed to do this kind of thing after they went to court, but it has been months since I read about them. Does anyone know to whom you would apply and how in order to get such an exception? They need a direction to work on.

Gordon?

Joanne Hollane DVM/MD Drain, Oregon.

[Guest guest]

From Drain,

So I contacted my congressman's office, (Defazio) about finding a way to get a local exception to the regulation limiting the pricing of office visits to the medicare amounts, and forbidding us to have retainer practices for smaller amounts if we are also taking medicare. I put it to them that as of this week we have now had all the mills in Southern Oregon close, all the mines in Southern Oregon close, that 60% of my town's previously employed people are not now employed and that these uninsured are going to flood the single sliding scale federally funded clinic thirty miles away in Roseburg beyond capacity.

The congressman's office has agreed to help facilitate this, particularly aiming at underserved areas.

My memory is that there were one or two small exception practices that were allowed to do this kind of thing after they went to court, but it has been months since I read about them. Does anyone know to whom you would apply and how in order to get such an exception? They need a direction to work on.

Gordon?

Joanne Hollane DVM/MD Drain, Oregon.

[Guest guest]

A “special case” solution

might be your best way forward, and in creating a special case you can gently

remind folks that good primary care docs working for their communities shouldn’t

have to find “special case” support to do their work.

There are a couple of ways to change

financing to help these folks. The problem is that creating a new payment

structure takes a lot of time and money. It has to happen, but it won’t

happen soon and you need a solution soon. Long term changes must include

fundamental reform of the payment system

Short term you can suggest either of the

following (I have more detail and can talk if it looks like you might move on

this):

1: Enhanced conversion factor.

This simply adds to how much you get for each CPT4 code. Not a great

improvement in methodology but at least the dollars are better (you’d

have to negotiate a substantial increase in conversion factor for this to be true).

2: Typical FFS with same conversion

factor and add an “enrollment” fee.

This rewards you for all the non-visit

work but requires some modification of the payment system. The ideal

would have a case-mix adjusting methodology but that’s likely to be

expensive and complex. Right now I’d assume that most of the folks

are pretty complex (if only due to the lack of income).

These both present a foot in the door of

payment reform. I’d push more for # 2 as it begins to reflect the

real work of primary care. I’d propose that the extra payments are

reasonable based on the high quality of care in your practice and show them

your patient experience data (as it reflects system properties of effective

primary care – which is the intervention that improves outcomes and

reduced down-stream costs).

Gordon

From: [mailto: ] On Behalf Of joanne holland

Sent: Wednesday, November 19, 2008

1:03 PM

To:

Subject: Re:

Need help. Working from within.

From Drain,

So I contacted

my congressman's office, (Defazio) about finding a way to get a

local exception to the regulation limiting the pricing of office visits

to the medicare amounts, and forbidding us to have retainer practices for

smaller amounts if we are also taking medicare. I put it to them that

as of this week we have now had all the mills in Southern Oregon close, all

the mines in Southern Oregon close, that 60% of my town's previously employed

people are not now employed and that these uninsured are going to flood the

single sliding scale federally funded clinic thirty miles away in

Roseburg beyond capacity.

The congressman's

office has agreed to help facilitate this, particularly aiming at

underserved areas.

My memory is

that there were one or two small exception practices that were allowed to do

this kind of thing after they went to court, but it has been months since I

read about them. Does anyone know to whom you would apply and how

in order to get such an exception? They need a direction to work on.

Gordon?

Joanne Hollane DVM/MD Drain, Oregon.

[Guest guest]

You are right, you can only have one fee for a 99213, but my old biller used to say " if you want to charge a cash pay patient lower than your fee schedule, then don't code it a 99213. Just call it " OV " and don't call it any specific CPT code. " That seems to work, as does giving a discount that is a standard percentage off the regular fee schedule and is for " payment at the time of service " .

if you take medicrae yes you get in trouble You can have only one fee schedule.If you do not take medicare I guess this would fly

I have been thinking about this too. There are many factories closing or drastically cutting back nearby (RV industry). I now have more patients without insurance and expect it to get worse. I am usually off (haha, doing paperwork) on Thursdays and thought...........could I offer walk in appts for 2-3 hours, just on Thursdays -->one problem only $35........ " Thrifty Thursdays " ! I figure this could work for those pts I am not contracted with and might help a few folks. Is there something I am overlooking legally, like with CMS that will not allow me to do this?

Ortega-Schmitt

From: Dr Levin <dr_levincomcast (DOT) net>Subject: Re: [Practiceimprovemen t1] Need help. Working from within.To: Practiceimprovement 1yahoogroups (DOT) com

Date: Sunday, November 23, 2008, 7:01 AM

So what is diferent with your practice vs others in area (a Dr Bruce Carlson who says his clinics contract at 160% of Medicare in Oregon at AAFP's listserv).

Don't your private insurers pay about 120% of Medicare?

Matt in Western PA

Re: [Practiceimprovemen t1] Need help. Working from within.

From Drain,

So I contacted my congressman' s office, (Defazio) about finding a way to get a local exception to the regulation limiting the pricing of office visits to the medicare amounts, and forbidding us to have retainer practices for smaller amounts if we are also taking medicare. I put it to them that as of this week we have now had all the mills in Southern Oregon close, all the mines in Southern Oregon close, that 60% of my town's previously employed people are not now employed and that these uninsured are going to flood the single sliding scale federally funded clinic thirty miles away in Roseburg beyond capacity.

The congressman' s office has agreed to help facilitate this, particularly aiming at underserved areas.

My memory is that there were one or two small exception practices that were allowed to do this kind of thing after they went to court, but it has been months since I read about them. Does anyone know to whom you would apply and how in order to get such an exception? They need a direction to work on.

Gordon?

Joanne Hollane DVM/MD Drain, Oregon.

-- If you are a patient please allow up to 12 hours for a reply by email/

please note the new email address.Remember that e-mail may not be entirely secure/ MD ph fax

-- Annie SkaggsLexington, KY

[Guest guest]

I have spent a little time on the question about being a medicare participating provider and charging uninsured/underinsured patients a lower fee than your usual charge. My medicare intermediary office insisted I had to have one fee schedule and charge everyone the same. However, on searching the manuals and attorney opinions on the internet, it seems that we can charge different fees- particularly for the uninsured/cash patient.

The original rule re: a prohibition on charging medicare "in excess of usual charges" dates back to late 1980s- but there were no guidelines on what consituted usual charges. In 2003, the OIG proposed a somewhat complicated rule change that better defined the "usual charge" calculation but decided in 2007 not to implement it. In several posts, the general opinion was that if you charged cash patients, no lower than the medicare allowable fee, you were probably going to be okay.

The most up to date info was from June 2007- if anyone knows of updates to this rule since then, please forward. Here is an excerpt from http://www.mintz.com/newsletter/2007/Health-Alert-OIG-Excess-06-07/index.htm:

Finally, the OIG made clear that, when evaluating usual charges for purposes of the substantially in excess provision, providers and suppliers do not need to consider free or substantially reduced charges offered to uninsured or underinsured patients who are self-paying patients.

Carla Gibson

From: Dr Levin <dr_levincomcast (DOT) net>Subject: Re: [Practiceimprovemen t1] Need help. Working from within.To: Practiceimprovement 1yahoogroups (DOT) comDate: Sunday, November 23, 2008, 7:01 AM

So what is diferent with your practice vs others in area (a Dr Bruce Carlson who says his clinics contract at 160% of Medicare in Oregon at AAFP's listserv).

Don't your private insurers pay about 120% of Medicare?

Matt in Western PA

Re: [Practiceimprovemen t1] Need help. Working from within.

From Drain,

So I contacted my congressman' s office, (Defazio) about finding a way to get a local exception to the regulation limiting the pricing of office visits to the medicare amounts, and forbidding us to have retainer practices for smaller amounts if we are also taking medicare. I put it to them that as of this week we have now had all the mills in Southern Oregon close, all the mines in Southern Oregon close, that 60% of my town's previously employed people are not now employed and that these uninsured are going to flood the single sliding scale federally funded clinic thirty miles away in Roseburg beyond capacity.

The congressman' s office has agreed to help facilitate this, particularly aiming at underserved areas.

My memory is that there were one or two small exception practices that were allowed to do this kind of thing after they went to court, but it has been months since I read about them. Does anyone know to whom you would apply and how in order to get such an exception? They need a direction to work on.

Gordon?

Joanne Hollane DVM/MD Drain, Oregon. -- If you are a patient please allow up to 12 hours for a reply by email/please note the new email address.Remember that e-mail may not be entirely secure/ MD ph fax

-- Annie SkaggsLexington, KY

[Guest guest]

I have spent a little time on the question about being a medicare participating provider and charging uninsured/underinsured patients a lower fee than your usual charge. My medicare intermediary office insisted I had to have one fee schedule and charge everyone the same. However, on searching the manuals and attorney opinions on the internet, it seems that we can charge different fees- particularly for the uninsured/cash patient.

The original rule re: a prohibition on charging medicare "in excess of usual charges" dates back to late 1980s- but there were no guidelines on what consituted usual charges. In 2003, the OIG proposed a somewhat complicated rule change that better defined the "usual charge" calculation but decided in 2007 not to implement it. In several posts, the general opinion was that if you charged cash patients, no lower than the medicare allowable fee, you were probably going to be okay.

The most up to date info was from June 2007- if anyone knows of updates to this rule since then, please forward. Here is an excerpt from http://www.mintz.com/newsletter/2007/Health-Alert-OIG-Excess-06-07/index.htm:

Finally, the OIG made clear that, when evaluating usual charges for purposes of the substantially in excess provision, providers and suppliers do not need to consider free or substantially reduced charges offered to uninsured or underinsured patients who are self-paying patients.

Carla Gibson

From: Dr Levin <dr_levincomcast (DOT) net>Subject: Re: [Practiceimprovemen t1] Need help. Working from within.To: Practiceimprovement 1yahoogroups (DOT) comDate: Sunday, November 23, 2008, 7:01 AM

So what is diferent with your practice vs others in area (a Dr Bruce Carlson who says his clinics contract at 160% of Medicare in Oregon at AAFP's listserv).

Don't your private insurers pay about 120% of Medicare?

Matt in Western PA

Re: [Practiceimprovemen t1] Need help. Working from within.

From Drain,

So I contacted my congressman' s office, (Defazio) about finding a way to get a local exception to the regulation limiting the pricing of office visits to the medicare amounts, and forbidding us to have retainer practices for smaller amounts if we are also taking medicare. I put it to them that as of this week we have now had all the mills in Southern Oregon close, all the mines in Southern Oregon close, that 60% of my town's previously employed people are not now employed and that these uninsured are going to flood the single sliding scale federally funded clinic thirty miles away in Roseburg beyond capacity.

The congressman' s office has agreed to help facilitate this, particularly aiming at underserved areas.

My memory is that there were one or two small exception practices that were allowed to do this kind of thing after they went to court, but it has been months since I read about them. Does anyone know to whom you would apply and how in order to get such an exception? They need a direction to work on.

Gordon?

Joanne Hollane DVM/MD Drain, Oregon. -- If you are a patient please allow up to 12 hours for a reply by email/please note the new email address.Remember that e-mail may not be entirely secure/ MD ph fax

-- Annie SkaggsLexington, KY

[Guest guest]

Keep same fee schedule for ALL -- and give % off "same as cash" discount.

My biller says this is fine, and the person can apply the ENTIRE nondiscounted amount off of a deductable.

Matt in Western PA

Re: [Practiceimprovemen t1] Need help. Working from within.

From Drain,

So I contacted my congressman' s office, (Defazio) about finding a way to get a local exception to the regulation limiting the pricing of office visits to the medicare amounts, and forbidding us to have retainer practices for smaller amounts if we are also taking medicare. I put it to them that as of this week we have now had all the mills in Southern Oregon close, all the mines in Southern Oregon close, that 60% of my town's previously employed people are not now employed and that these uninsured are going to flood the single sliding scale federally funded clinic thirty miles away in Roseburg beyond capacity.

The congressman' s office has agreed to help facilitate this, particularly aiming at underserved areas.

My memory is that there were one or two small exception practices that were allowed to do this kind of thing after they went to court, but it has been months since I read about them. Does anyone know to whom you would apply and how in order to get such an exception? They need a direction to work on.

Gordon?

Joanne Hollane DVM/MD Drain, Oregon. -- If you are a patient please allow up to 12 hours for a reply by email/please note the new email address.Remember that e-mail may not be entirely secure/ MD ph fax

-- Annie SkaggsLexington, KY

[Guest guest]

I continue my search for info "from the mouth of medicare" via the federal register... the federal register proposed rules in 2003 regarding providers charging fees in excess of usual charges, excluded physicians and physician services (my interpretation) and seemed to indicate that because physicians had a fee schedule, it was moot point. The subsequent June 18, 2007 Federal Register document indicating the OIG was not going to implement the rule, states: Nothing in this withdrawal notice affects OIG's long-standing interpretation of the statute in this regard, and it continues to be OIG's position that, when calculating their ``usual charges'' for purposes of section 1128((6)(A) of the Act, individuals and entities do not need to consider free or substantially reduced charges to (i) uninsured

patients or (ii) underinsured patients who are self-pay patients for the items or services furnished.

The intent is that if a provider is charging other payers fees lower than the Medicare allowable, but charging Medicare a higher rate to obtain the highest reimbursement, then they have a problem... However, the penalty for such behavior is exclusion from gov't sponsored plans for 3 years--- automatic "opt out" without the hassle of completing their forms to do so....

Carla Gibson

From: Dr Levin <dr_levincomcast (DOT) net>Subject: Re: [Practiceimprovemen t1] Need help. Working from within.To: Practiceimprovement 1yahoogroups (DOT) comDate: Sunday, November 23, 2008, 7:01 AM

So what is diferent with your practice vs others in area (a Dr Bruce Carlson who says his clinics contract at 160% of Medicare in Oregon at AAFP's listserv).

Don't your private insurers pay about 120% of Medicare?

Matt in Western PA

Re: [Practiceimprovemen t1] Need help. Working from within.

From Drain,

So I contacted my congressman' s office, (Defazio) about finding a way to get a local exception to the regulation limiting the pricing of office visits to the medicare amounts, and forbidding us to have retainer practices for smaller amounts if we are also taking medicare. I put it to them that as of this week we have now had all the mills in Southern Oregon close, all the mines in Southern Oregon close, that 60% of my town's previously employed people are not now employed and that these uninsured are going to flood the single sliding scale federally funded clinic thirty miles away in Roseburg beyond capacity.

The congressman' s office has agreed to help facilitate this, particularly aiming at underserved areas.

My memory is that there were one or two small exception practices that were allowed to do this kind of thing after they went to court, but it has been months since I read about them. Does anyone know to whom you would apply and how in order to get such an exception? They need a direction to work on.

Gordon?

Joanne Hollane DVM/MD Drain, Oregon. -- If you are a patient please allow up to 12 hours for a reply by email/please note the new email address.Remember that e-mail may not be entirely secure/ MD ph fax

-- Annie SkaggsLexington, KY

[Guest guest]

RE was not making light of your circumstance -- just at the AAFP listserv, we are constantly perplexed how this Dr Bruce Carlson says he takes only insurance programs thru his IPA that pays 160% of Medicare as he's in "underserved area of Oregon."

He uses 3 PAs in rural clinics though, it sounds more like a Rural Health Center to me, but he says not.

In PA, solo like me too as an FP, I had to give up new Medicaids as they paid only 1/2 of Medicare levels and all of the aggravation.

I'm fortunate that as of now, most of my insured base appears relatively stable, but of course this could change.

Wish you well with self payors -- I have NEVER heard of a restriction REQUIRING you NOT to take more than Medicare?

Matt in Western PA

Re: [Practiceimprovemen t1] Need help. Working from within.

From Drain,

So I contacted my congressman' s office, (Defazio) about finding a way to get a local exception to the regulation limiting the pricing of office visits to the medicare amounts, and forbidding us to have retainer practices for smaller amounts if we are also taking medicare. I put it to them that as of this week we have now had all the mills in Southern Oregon close, all the mines in Southern Oregon close, that 60% of my town's previously employed people are not now employed and that these uninsured are going to flood the single sliding scale federally funded clinic thirty miles away in Roseburg beyond capacity.

The congressman' s office has agreed to help facilitate this, particularly aiming at underserved areas.

My memory is that there were one or two small exception practices that were allowed to do this kind of thing after they went to court, but it has been months since I read about them. Does anyone know to whom you would apply and how in order to get such an exception? They need a direction to work on.

Gordon?

Joanne Hollane DVM/MD Drain, Oregon.