Fam Pract Manag. 1999 Apr;6(4):50.
- Pediatricians joining family physicians
- Using “reciprocal billing” arrangements
- Contracting with MSOs
- Medicare HMOs and out-of-network providers
Pediatricians joining family physicians
I'm in a small family practice group with two physicians and one nurse practitioner. Our administrators are interested in bringing a pediatrician into our office. I believe this addition will prevent me from having a large pediatric panel and will cause me to lose patients. What happens to a family practice when a pediatrician joins the group?
Without a doubt, adding a pediatrician to a family practice group steers children into the pediatrician's practice. The only way to preserve a traditionally balanced practice composition for family physicians in a mixed-model practice is to add internists and pediatricians in amounts that represent the population in the practice community and the predicted visit demands.
Communities, and hence primary care practices, usually demand more adult care than care for children (since the elderly tend to require more visits per person annually). In a small practice, one pediatrician is usually more than enough to care for all the children. While adding the pediatrician will usually change the mix for the other providers, it may also recruit other family members into the practice.
The changes brought by new partners with different scopes of practice can be viewed as welcome consequences of a good plan as long as you anticipate the visit demands and the impact of those demands on the physicians involved.
Using “reciprocal billing” arrangements
I'm a locum tenens physician in a rural health clinic, and I am about to take maternity leave. As part of coverage during my absence, I've arranged for three emergency physicians to see patients at the clinic for five hours a day, three days a week. They will be reimbursed by the hospital at an hourly wage. How should we bill for their services? May I continue to use my billing number for the rural health clinic and for claims to Medicaid, Medicare and our insurance companies? It seems silly to apply for provider numbers for each of these three physicians for such a short time.
Medicare does allow for “reciprocal billing” arrangements that would permit you to bill under your provider number for the services of the three emergency physicians, assuming certain conditions were met. For example, the arrangement can't continue over a continuous period of more than 60 days, and you will need to attach modifier -Q5 to the service codes on the claims. Contact the provider relations staff of your Medicare carrier for more information on reciprocal billing arrangements. Your state Medicaid agency and some of your insurers might have similar provisions, but you should check with them to be sure.
Contracting with MSOs
Many management service organizations (MSOs) charge physicians a percentage of revenue (collections) as their fee. Medicare regulations prohibit percentage-of-collections fees for MSO service unless an MSO only transmits bills (i.e., provides no coding or other services). Does contracting with an MSO put a physician at legal risk?
Most MSOs do more for participating physicians than simply transmit bills for payment. Any MSO arrangement requires legal review to ensure that both the relationships created and the services provided comply with the law, particularly fraud and abuse prohibitions.
Guidelines for billing companies issued by the Office of the Inspector General (OIG) in November 1998 are applicable to MSOs. They state that “the OIG has a long-standing concern that percentage billing arrangements may increase the risk of upcoding and similar abusive billing practices.” And, “for billing companies that provide marketing services, percentage arrangements may implicate the antikickback statute.”
In addition to having the arrangement reviewed by attorneys, the MSO and its physicians should have an appropriate compliance program in place.
Medicare HMOs and out-of-network providers
Can Medicare HMOs unilaterally reduce usual-and-customary reimbursement to the level of the Medicare fee schedule for authorized services provided by non-HMOcontract physicians?
Yes. A Medicare HMO is required to pay for reasonable emergency services, urgently needed services and referral services, even when furnished by providers with whom the HMO has no formal arrangements for payment. A physician who participates in fee-for-service Medicare and is not under contract with the Medicare HMO, but who provides services to an HMO enrollee, is paid according to Medicare's physician fee schedule. The physician must accept this as payment in full. If the physician does not participate in Medicare, the charge is subject to the standard limitation on charges by nonparticipating physicians providing services to fee-for-service Medicare patients.
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