MH Exclusive: Price backs balance billing for Medicare patients

[Bill Peckham]

http://www.modernhealthcare.com/article/20170309/NEWS/170309880


MH Exclusive: Price backs balance billing for Medicare patients
By Virgil Dickson  | March 9, 2017

HHS Secretary Tom Price is backing legislation that will allow physicians to bill seniors for charges that are more than the rates approved by Medicare. He claims the move would draw more physicians to enroll in the program.

In correspondence between Price and the Senate Finance Committee provided exclusively to Modern Healthcare, Price said he supports enacting such a law, which several physician groups said could backfire.

Current law does not allow physicians participating in Medicare to bill patients more than the program's payment rate for any service. Doctors not in the Medicare program can balance. But in response to a query from Sen. Bill Nelson (D-Fla.) during his confirmation process, Price said he favored changing the law to let doctors recoup unreimbursed Medicare costs, a practice known as balance billing.

Price, a retired orthopedic surgeon, said balance billing would entice more providers to work with Medicare beneficiaries. Patients typically get "surprise" bills when a physician practice operating inside a hospital isn't part of an insurer's network. It's been happening more frequently in recent years as insurers select fewer providers for their networks to keep premiums down. Several states have passed measures to prevent the practice.

During his time in the House, Price introduced legislation to allow balance billing numerous times. The idea never gained traction.

Now, as secretary of HHS with the ear of President Donald Trump and a member of the party that controls both chambers of Congress, he is in a better position to make that long-desired change a reality. A spokesman for Price declined to expand on his written comments.

As part of Price's confirmation process, Nelson and other senators questioned Price about his stances on healthcare policy, including Medicare. Nelson, an opponent of balance billing, said most Medicare beneficiaries have limited incomes and may not have the financial resources to pay a provider for the excess price of services beyond what's covered by Medicare.

Price insisted the change would spark major, positive changes for Medicare members by increasing the number of physicians willing to see Medicare patients. However, according to the March 2016 Medicare Payment Advisory Commission report, "most beneficiaries report they are able to obtain timely appointments for routine care, illness, or injury, and most beneficiaries are able to find a new doctor without a problem."

Anders Gilberg, senior vice president of government affairs for the Medical Group Management Association, said many physician practices “would support this legislation in concept,” given how provider payments in Medicare have lagged behind inflation for the past decade. The Association of American Physicians and Surgeons, a far-right provider group, and the American College of Physicians also supported the idea.

Representatives from the American Medical Group Association and American Academy of Family Physicians said that the approach might lead providers to limit their Medicare patients to those who agree to balance billing,

The change in law could be “a little dangerous,” potentially creating inequitable access for low-income people, according to Shawn Martin, senior vice president for policy at AAFP.

[Bill Peckham]

This is not politics, it is policy. For people with chronic disease, particularly people who use dialysis this is a risky policy.


Balance billing by nephrologists could limit access to dialysis rather than increase it, even more than today your zip code would determine the level of care you receive. Look into this issue and ask your Congressional representative's office about their position RE Balance Billing for Medicare beneficiaries.

[tigtink]

Thanks for posting this, Bill. That is very troubling. It would have serious consequences for most of us. I would not be able to live independently if I has to pay even more than I pay now.

[LorinnPKD]

Thank you, Bill. 

[Simon Dog]

The Norman Parathyroid surgery center (www.parathyroid.com) already balance bills.

It takes the form of a mandatory pre-surgical consultation with one of the center MDs.  The terms are - surgery covered by Medicare, but surgery will not be performed unless one of their staff MDs evaluates you (no, they will not accept an evaluation from another MD), and this evaluation is not covered by any insurance.   They further warn the patients that they are not to submit a claim or attempt to collect for this fee from their insurance carrier.   The fee varies by residential location (local; in-state; out of state) even though the patient goes to the center for evaluation and treatment.

This smells like "balance billing" under another name, and the caution to "not attempt to collect insurance payment" makes me suspicious that this practice understands this and is trying to keep off the radar.

Thoughts anyone?   Should I be contacting the Medicare fraud office?

[Michael Murphy]

First about the Medicare is a money looser for doctors and hospitals,  if was a money looser why do so many doctors and hospitals advertise for Medicare patients on tv.  The truth is the Medicare rates are calculated to provide a modest profit for the provider.  But in this day in age many like the jerk head of the hhs want obscene profits.  This is one example of the Trump administration shearing the sheep who elected them.  A move to Canada is looking better every day these hookless are trying to run the government.

[iolaire]

The Norman Parathyr.

Thoughts anyone?   Should I be contacting the Medicare fraud office?

Sounds like sketchy business to me.   Also I'd be worried about what other sketchy stuff that they are doing that you don't know about. Yes report them to Medicare. If they are following the rules they have nothing to fear.

Why do they operate on 100% of patients even those with negative tests?

[Simon Dog]

First about the Medicare is a money looser for doctors and hospitals,  if was a money looser why do so many doctors and hospitals advertise for Medicare patients on tv.  The truth is the Medicare rates are calculated to provide a modest profit for the provider.  But in this day in age many like the jerk head of the hhs want obscene profits.  This is one example of the Trump administration shearing the sheep who elected them.  A move to Canada is looking better every day these hookless are trying to run the government.

There is a difference between fully burdened profit and incremental overhead.   A great example is a multi-million dollar scanner that is used 50% of the time.  Boost that to 60% of the time and the average equipment cost per scan decreases.

Same with dialysis.    If the centers weren't making an incremental profit on additional dialysis patients, they would not accept Medicare.   No law requires a provider to accept Medicare, however, there are rules that come into play once a provider starts accepting it.    On the other hand, there is a good chance that medicare centers would be running at a loss if all patients paid the Medicare rate.

A move to Canada is looking better every day these hookless are trying to run the government.

Be careful .... I don't think you can just move into Canada, eh? and cash in on their public health care.

[Michael Murphy]

At the rate the trump admin is wrecking or at least trying I won't have much health insurance left any way.i still can't see a path for this to get by congress.

[Bill Peckham]

Here is a longer explaination of Balance billing
http://kff.org/medicare/issue-brief/paying-a-visit-to-the-doctor-current-financial-protections-for-medicare-patients-when-receiving-physician-services/

The Norman Parathyroid surgery center (www.parathyroid.com) already balance bills.

It takes the form of a mandatory pre-surgical consultation with one of the center MDs.  The terms are - surgery covered by Medicare, but surgery will not be performed unless one of their staff MDs evaluates you (no, they will not accept an evaluation from another MD), and this evaluation is not covered by any insurance.   They further warn the patients that they are not to submit a claim or attempt to collect for this fee from their insurance carrier.   The fee varies by residential location (local; in-state; out of state) even though the patient goes to the center for evaluation and treatment.

This smells like "balance billing" under another name, and the caution to "not attempt to collect insurance payment" makes me suspicious that this practice understands this and is trying to keep off the radar.

Thoughts anyone?   Should I be contacting the Medicare fraud office?

I'm not sure this is balance billing. I think this line on parathyroid.com covers them "All patients have the right to come to Tampa for an in-person consultation and thus the phone consultation would not apply--so just let us know if this is what you want." If it is optional then I think Medicare allows it.

[Charlie B53]

Once upon a time,  Yeah, I know, this sounds like a Fairy Tale, but really, a trip to the Hospital, Labs, X-Rays, Dr's consults, all came included in ONE Final Bill containing a breakdown of ALL the charges.

Insurance Companies' made contract agreements to pay 'Allowable charges' which resulted in often significant reductions to each individual charge listed within that 'Final Bill'. 

Somewhere along the line many of these 'Providers' included in this 'Final Billing' system decided they could make far more money if they opted out of the system and began billing individually.  Often I get many of these 'related expense' bills that have NEVER been submitted to my Insurance provider.

I am going to have to start reading all that 'fine print' on my next admission as I am sure that buried within there are something that allows all these 'related expense' billings.  I'm not going to sign it.

I have all these Companies calling me dunning me for payments, I just have to laugh.  As a Veteran I am very fortunate, ALL Charges must be submitted to the VA within 30 DAYS or they are DENIED as 'Untimely' and Federal Law BARS collection from the Veteran for any Providers failure to submit billing in a 'timely' manner.    This law needs to be extended to everyone.

Providers need to consolidate billing so any and every patient KNOWS exactly what charges apply to any hospital stay/treatment.  This current system many of these charges are not found out until received in the mail, often months later.

[Shaks24]

For those of us on Medicare it is also important to make sure providers we use accept Medicare Assignment. That means they are bound by law to accept the amount Medicare pays for a given service. If you do not you could end up owing additional money beyond what Medicare pays. For me I use original Medicare with Medigap F which covers just about everything else except prescriptions. I just always check providers I plan to use to make sure they accept Medicare assignment. Man I wish we just had a universal single provider system for this country. It would make things so much simpler and provide peace of mind to so many. This balance billing thing if ever passed would just add another level of expense and complexity for us. Tom Price is a heartless SOB in my opinion.

[Simon Dog]

I'm not sure this is balance billing. I think this line on parathyroid.com covers them "All patients have the right to come to Tampa for an in-person consultation and thus the phone consultation would not apply--so just let us know if this is what you want." If it is optional then I think Medicare allows it.

Interesting point I missed.   Probably there as a work-around so they can claim it is not balance billing while doing it.

Insurance Companies' made contract agreements to pay 'Allowable charges' which resulted in often significant reductions to each individual charge listed within that 'Final Bill'. 

Dialysis charges paid (not just billed, actual paid amount) on my behalf:

Medicare: Under $300 per teratment
Private insurance: $445 per treatment
Private insurance, out of network: $5050 at a DaVita clinic; $3000 at an FMC clinit

[cattlekid]

This reminds me of back in 2011 when I switched from in-center dialysis to home hemo.  The center where I was dialyzing did not offer NxStage so it also meant a switch from FMC to DaVita, which was the closest center to my home that offered NxStage.

I was still in the 30 month coordination period so my employer insurance was paying the big bucks for my treatments.  I knew the center saw dollar signs when I arrived.  When I told them I was leaving, I knew from reading here and elsewhere that the FA's rear end was going to be in a sling with his higher-ups.  The cash cow was leaving!  Sure enough, he paid me my one and only personal visit shortly after I dropped that news to find out how he could keep me from leaving.  I told him that unless he had a NxStage training program that he had stashed somewhere at the clinic that no one knew about, there was no way to keep me around.  Then he tried to coerce me to stay within the FMC network by telling me that FMC had a clinic about 10 miles out of my way that had NxStage.  Sorry buddy, really not my problem. 

Just goes to show how one or two people who are in the coordination period can really make or break the finances of a center. 

Same with dialysis.    If the centers weren't making an incremental profit on additional dialysis patients, they would not accept Medicare.   No law requires a provider to accept Medicare, however, there are rules that come into play once a provider starts accepting it.    On the other hand, there is a good chance that medicare centers would be running at a loss if all patients paid the Medicare rate.

[Simon Dog]

I knew the center saw dollar signs when I arrived. 

I have always thought that private insurance patients should get happy ending treatments 

[Simon Dog]

Resurrecting an old thread with new info:

It turns out my theory about parathyroid.com/Dr Norman engaging in "mediocare balance billing" under another name was spot on:

https://www.justice.gov/usao-mdfl/pr/owner-tampa-parathyroid-practice-agrees-pay-4-million-resolve-false-claims-act

Now, they call it a "second opinion" and offer to do it remotely, outside of Medicare, as an "option" at the same price for the consult they used to require.   I think they set it up so you need the consult, but have to get it in person on a separate date and trip to Tampa to avoid paying out of pocket.   That Dr. is simply not interested in working at the Medicare rate, but still wants access to that patient pool.

I'm not sure this is balance billing. I think this line on parathyroid.com covers them "All patients have the right to come to Tampa for an in-person consultation and thus the phone consultation would not apply--so just let us know if this is what you want." If it is optional then I think Medicare allows it.

Interesting point I missed.   Probably there as a work-around so they can claim it is not balance billing while doing it.

Insurance Companies' made contract agreements to pay 'Allowable charges' which resulted in often significant reductions to each individual charge listed within that 'Final Bill'.