Medicare Compliance & Reimbursement

Watch for gray areas of services Medicare may or may not cover.

Medical practices that charge patients a monthly or annual fee for extra attention could receive some extra attention from the feds.

Two warnings: The feds have warned against so-called "concierge care" twice in recent years. In 2002, then-HHS Secretary Tommy Thompson wrote a letter to Rep. Henry Waxman (D-CA) explaining that physicians aren't allowed to bill Medicare patients for any services that Medicare might cover, notes John Marquis, an attorney with the firm of Warner, Norcross and Judd in Grand Rapids, MI.

Then, the HHS Office of Inspector General (OIG) issued a fraud alert in March 2004 about "Added Charges For Covered Services." The OIG said it had alleged that a particular physician violated his assignment agreement by charging an annual fee of $600 for spending more time with patients even though Medicare was already paying for the visits.

Since those warnings came out, providers are "being more cautious," says Wayne Miller with Compliance Law Group in Woodland Hills, CA. But Miller still sees a lot of interest in this topic among providers.

The bottom line: If providers want to charge a higher fee for extra time or attention, [the service] should be something that Medicare doesn't cover, Miller explains. Unfortunately, experts disagree on what Medicare is and isn't paying for through its fee schedule.

Not covered: Clearly Medicare doesn't cover certain services - or doesn't cover them as adequately as it could. For example, if a physician provides a lot of counseling on nutrition, pharmacological issues or lifestyle, Medicare won't consider the services medically necessary - and the most your physician can bill for is the lowest level evaluation and management code, notes Miller. Accordingly, providers rendering these services may wish to alter their fees to secure more acceptable payment.

Counseling and other types of "wellness" visits are very valuable to patients, and Medicare doesn't cover them apart from the one-time "Welcome to Medicare" exam.

In addition to counseling and preventive care, there's a slew of other non-covered services that physicians may wish to charge for. Some primary care doctors will promise to go with the patient when he or she has to visit a specialist, notes Allan Jergesen, an attorney with Hanson, Bridgett, Marcus, Vlahos and Rudy in San Francisco. Or if another physician admits the patient to the hospital, the "concierge" doctor may promise to come visit the patient in the hospital every day, even if he or she isn't the attending physician. Providers can legitimately charge for these types of services, Jergesen says.
 
Gray area: If a physician promises to provide more access to patients than a normal physician would provide, she could argue that Medicare doesn't pay for that service, says Miller. [...]