A Few Lessons From My Hybrid Practice
Author: Sarah Zaheer, MD
Like most doctors starting out in DPC, I chose to stay opted in for practical reasons. For a few months, it really did not matter but then I started getting calls from Medicare patients and I realized I really wanted to take these patients on. So, I sought legal advice, and after a lot of effort, I finally figured out how to submit claims on my own. I opted to be a non-participating Medicare provider. In a nutshell, what that means is that patients pay for the practice at the time of service and then later I submit their claims. In a few weeks’ time, patients will receive checks from Medicare and their secondary.
The pros of this setup is that I do not have to chase Medicare for payments. I am unsure if this is true, but the general thought is that you can bill a bit higher as well. This would be the Non-Facility Limiting Charge. You can look up what the rates for your area would be for different types of visits via this link:
https://www.cms.gov/medicare/physician-fee-schedule
For patients, it is an easy buy-in, since it will not cost them much. Patients understand that their secondary insurance may not want to pay, and their checks would be 80% of what they paid. Since patients are receiving such fantastic care, no one complains about being $10-$20 short. The majority of patients, however, received payments from their secondary insurance. In contrast to the Medicare checks which take about 1- 3 weeks, these took several months to arrive.
I will say this attracted some patients who might not have picked a nontraditional practice. Retirees did not have to worry about out-of-pocket costs. These patients also added diversity and breadth to the type of medical conditions I saw.
For a while it worked, but here is a list of issues I faced:
1. Some patients familiar with Medicare pitfalls questioned my commitment to the Direct Primary Care model
2. Some patients did not receive their checks. On the Novitasphere portal the claim status clearly stated, “Approved and Paid”, but the patient reports they got nothing of that sort in their mail. Upon further investigation, the only reasonable conclusion was that their mail had been compromised and stolen.
3. Secondary insurance decided to send checks to me, instead of the patient. They included several patients’ payments in one check. There was always a statement detailing the payments, but it took me many after clinic hours to sort it all out.
4. Patients love being able to message me and email me. If I needed to send a prescription or put an order, I would have to create an encounter and then subsequently bill that encounter. I think this took away some of the efficiency DPC offers.
5. Medicare rates drop a few dollars every quarter. Sometimes they go up, but they are always changing.
6. Sometimes the claims were denied, and I had to spend a lot of time figuring out why and then re-submit.
7. Not surprisingly, the administrative load for this small subset of my patients took a huge chunk of my time.
I am now in the process of opting out. While for some patients, this is welcome news. These are the folks who sought me for the Direct Primary Care model and constantly worried if I was being compensated appropriately. For others this is all very confusing, and I am faced with the possibility of them leaving the practice. I am yet again another doctor in this area who has gone “concierge”. PCPs are hard to come by in this area and more importantly, the patients and I have built a rapport. I offered to see these patients for free, but they did not take me on that offer. The beauty of DPC is that we mostly figure out a win-win solution and I am hopeful we will land on yet another winning DPC solution for this also.
I was non-par for many years before going DPC. It was a mess, even CMS and a large billing company (whose name is shared by a famous Greek Goddess) never seemed to get it right.