This page contains a Flash digital edition of a book.
“Money is important, but the most precious commodity is time. Now I can practice medicine the way I was trained and take as much time as I need.”


continue[s] to increase the amount of paperwork we’re required to fill out to assure you receive the benefits to which you’re entitled,” legal records show. The practice explained the money was “par- tial compensation for the time your phy- sician and our staff spend assuring you receive prescription renewals quickly, maximum benefits from Medicare, and any secondary insurance, etc.” The federal government saw it differ-


On the flip side, administrative activi-


ties like preauthorizations and filling out forms may not be considered medical services at all. “If there were a recognized set of tasks that a practice performed that was sig- nificant in terms of time and complex- ity, and payers were willing to recognize that, they might see it as a separate ser- vice. Whether it would be covered or not is another matter,” Mr. Barton said. He pointed to a pilot within the Texas


Medicaid program that pays primary care practices an extra fee for case man- agement — having a dedicated, certified case manager to follow patients, make sure they keep their appointments and take their medications, and connect to any needed specialists. Blue Cross and Blue Shield of Texas


requires physician practices to sign an agreement before charging a formal medical home fee. That allows physi- cians to bill the payer for care coordina- tion services covered by the agreement. Blues representatives were not available to comment on the details of the medical home contract or other fee policies for noncovered services. TMA’s white paper says there is no “bright line” or clearly defined rule for


28 TEXAS MEDICINE May 2013


covered versus noncovered services in Medicare and no single list to refer to.


“According to the government, ‘there are many scenarios (ICD-9/CPT code combi- nations) that will determine if a code is covered or not,’” the analysis says. Mr. Barton says a key question for practices to ask themselves is, “What ex- actly are you doing that is different from anybody else? Communicating with pa- tients, keeping records, scheduling ap- pointments — that’s just being respon- sive and being a good doctor.”


Lack of guidance


Physician practices may want to consider themselves on notice following a recent settlement between a South Carolina medical group and the Department of Health and Human Services Office of In- spector General (OIG). Heritage Medical Partners LLC and four physicians agreed to pay $170,260 in civil penalties to settle allegations that an annual $50 administrative fee they charged patients violated Medicare rules. The group admitted no wrongdoing. The Hilton Head Island, S.C., prac- tice sent letters to 5,474 of its Medi- care patients requesting the fee because “the federal government (Medicare)


ently. It contends the services specified “are actually covered and reimbursable by Medicare.” Other than coinsurance and deductibles, the doctors could not collect additional payment, the settle- ment states. “Therein lies the rub,” said Heritage’s attorney, David W. Ball, of Greenville, S.C. “The basic rule is very easy to artic- ulate: Medical practices can’t bill Medi- care patients for covered services subject to Medicare rules. But there is a lack of clear guidance on what was covered and what is not,” and maybe this case will provide some guidance.


“My client is a small independent pri-


mary care practice in a trying environ- ment and wants to remain independent,” Mr. Ball said. “The real bottom line is, if doctors were getting adequately reim- bursed, they would not be doing this.” He says OIG agreed that dealing with things like secondary insurance filings and canceled office visits were not cov- ered Medicare services. But, overall, OIG took the position that many of the ser- vices Heritage was charging for — such as prescription renewals and on-call cov- erage — were rolled into an office visit and more or less part of a practice’s obli- gation to its patients.


Heritage, on the other hand, believed those activities went above and beyond the call of what Medicare required, and charged what Mr. Ball says was a nomi- nal fee in line with their value. Although it did not sway OIG, “our


argument was office visits for some pa- tients are few and far between, yet pre- scription renewals and other demands can come on very regular basis,” he said, adding that most patients opted to stay with the practice in spite of the fee. “To the extent something could be tied back to an office visit, even if it’s remote in


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40  |  Page 41  |  Page 42  |  Page 43  |  Page 44  |  Page 45  |  Page 46  |  Page 47  |  Page 48  |  Page 49  |  Page 50  |  Page 51  |  Page 52  |  Page 53  |  Page 54  |  Page 55  |  Page 56  |  Page 57  |  Page 58  |  Page 59  |  Page 60