MEDICAL ECONOMICS
Extra fee, extra hassle Charging patients extra fees may hurt, not help BY AMY LYNN SORREL As physician practices struggle to stay
viable, some have resorted to charging additional patient fees to make up for declining payments, rising costs, and scarce time that stack the odds against many doctors. The fee may come in different brands and sizes, labeled as an annual medical home fee, administrative charge, or direct payment for a membership of sorts for insured patients to stay in the practice.
But the idea is the same: Physicians are looking for a way to continue to give their patients high-quality, personalized care, while filling in the economic gaps created by the many things doc- tors say today’s health care sys- tem expects them to do but tends not to compensate. That could be anything from paperwork and prescription renewals to after- hours consults. Unlike concierge medicine, the extra-fees option appears to allow practices to continue seeing patients of all insurance stripes. While it sounds easy enough, some experts caution it may come with hidden consequences, and a recent federal enforcement action on the matter provides a cautionary tale. “If you are charging a fee just
Commercial health insurance contracts typically have simi-
lar provisions. Clauses barring balance billing also may come into play.
But payers generally allow physicians to charge patients for noncovered services when they notify patients in advance. Medicare refers to this as advance beneficiary notice (ABN). A 2010 TMA white paper on the subject warns, however, that such a notice is not blanket permission for doctors to charge patients when they aren’t paid for something. “Physicians should be extreme-
“The real bottom line is, if doctors were getting adequately reimbursed,
they would not be doing this.”
to keep the lights on, or continu- ing to do what you did before but putting a fancy name on it, that’s a problem,” says former TMA staff attorney Hugh M. Barton, of Austin.
Still, others attest it can be done right, albeit carefully, and can free physicians up for patient care.
Strict rules Aside from allowed deductibles and coinsurance, the Centers for Medicare & Medicaid Services (CMS) strictly prohibits bill- ing for services already covered by government programs.
ly careful in the use of ABNs, as charging a [Medicare] beneficia- ry for services the government considers to be covered (without regard to whether a payment by government is made) is a viola- tion of the terms of participation and Social Security laws (regard- less of whether one is or is not participating in the Medicare program),” the paper says. The only exception would be for phy- sicians who have filed a formal opt-out affidavit so they can pri- vately contract with patients. The whiter paper, “Advance Beneficiary Notice of Noncov- erage — Charging for Services Not Covered by Medicare,” is available in the TMA Medicare Resource Center at www.texmed. org/ABN_Charges.
The difference between what is covered and what is not, however, can be murky.
What doctors may consider additional services in the form of administrative tasks, for example, may in payers’ eyes al- ready be included in the covered services. That leaves what Mr. Barton says is a fairly narrow window of opportunity for physicians to charge for anything they might consider “extra.” Even now, health plans don’t always pay for covered ser- vices if they don’t consider them medically indicated, or if the payment is “bundled” with other services.
May 2013 TEXAS MEDICINE 27
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