Employer Plans and Billing

(Jonathan Wade) #1

So we have come across a small employer (25 employees) that wants to pay for our DPC services for all employees. The catch is that they have a few that are Medicare members. We have not opted out of Medicare at this point. How should we address this? Since the employer is paying 100% (not pay-roll deducted), could we still allow them to participate? Thanks.

(Jason Larsen) #2

Hi Jonathan,

Congratulations! That’s great that there’s an employer that recognizes the benefit for employees and is willing to pay 100%. Now the hard part comes in retaining that employer group!

While I’m not a lawyer (and please take my advice with that in mind), it is my understanding that since you have not opted out of Medicare, that you are unable to accept outside payment for those Medicare patients - since you have technically ‘contracted’ with Medicare, you cannot accept money for servicing Medicare patients outside of billing them directly (with their few exceptions - which is basically in emergency situations).

My advice to you would be to either…

  1. opt-out of Medicare (it has been wonderful for us!)
  2. let the employer know that you cannot accept membership for Medicare patients, so they will have to stay with their primary physician
  3. let the employer know that you cannot accept membership for Medicare patients, but those medicare patients will have the benefit of seeing you, but will have to be billed as normal through Medicare

I hope that’s helpful, Jonathan. Best of luck to you!


(pouya bahrami) #3

I have worked with a law firm to have mixed model. Just charge the Medicare patients FFS and don’t violate Medicare rules. How you treat the others is not Medicare’s concern. I am sure the employer doesn’t care because they don’t pay for the care of the Medicare employees. If they don’t have a secondary, or if the employer wants to let their secondary cancelled, then just eat the 20% and don’t charge the Medicare patients for it.
Sure you can always opt out.