CASH PAY PRACTICE

The Logistics & Implementation

Laura Cassidy, Clinic Manager

WHO AM I?• Business Manager for Lake Washington

Sports & Spine• Physician-owned PM&R clinic in Bellevue,

WA

• Hired to aid Dr. Hyman in starting the practice in January 2012• Main Role: Manage the day-to-day

business operations of our clinic so the physicians can focus on providing excellent patient care

THE PROBLEM

SIMPLICITY COMPLEXITY

CASH PRACTICE: WHY?• Do it for the right reasons• Autonomy, quality patient care, quality of life, simplicity• Don’t do it for money

• Be realistic• Is there a market for your services

• Evaluate your personal financial situation• Can you weather a year without income?• What is your ideal salary?

• Be very comfortable discussing your decision with staff and patients

IDENTIFY YOUR STRENGTHS

• Why should patients see YOU?• Differentiate yourself• What do you offer that’s unique?• What is your niche/ area of expertise?

• Self esteem: be your own biggest fan• Train your staff to be your second biggest fan

• Network with other area providers with similar mindsets• Areas where people are already paying directly for care (or have more

financial responsibility)• Fitness, anti-aging, chiropractic care, physical therapy

ASSESS, PLAN, ACTION

• Overhead deep-dive• Know exactly what you are spending money on• Where can you save money?

• Simplify• Evaluate necessity of each staff member’s role

• Will not need biller and coder in a direct pay environment

• Risk assessment & planning• Evaluate your patient demographics and income• Have clear knowledge of the income you need to cover your salary and overhead• Develop a business plan with a specific focus on marketing your value

• EDUCATION is key• Current patients• Local friends/ family• Area providers

• Insurance contract cancellation

CONTRACT CANCELLATION:RAPPEL vs. BASE JUMP

• 1280 × 960 - gentside.com

Strategic dropping of insurance contracts

Drop them all at once!

INSURANCE CONTRACT CANCELLATION:

WHERE TO STARTAssess and rank each insurance you are contracted with:• Payment per code/ time• Complexity of providing care• Prior auths, denials, appeals

• % of current patient population• Ex- Premera BCBS Microsoft in Seattle, WA

INSURANCE CONTRACT CANCELLATION

• Contact each insurance company you participate with to inquire about their contract termination procedures• Most are 90 days notice

• Notify patients via letter and email • Send certified, signature required letters of cancellation to insurance

companies• Once USPS confirmation of receipt is received, call each company to

ensure they logged it and are processing

What will happen when you cancel contracts?

• Various levels of support from fellow providers• Unpredictable reactions from patients• Confusion• Anger• Understanding

MEDICARE

“CMS is transparent, honest and easy to work with.

I really admire the way they conduct business.”- No physician ever

“I only wish more physicians would take this bold step. However the problem is also with the patient. Somehow they still believe that physicians make an excessive amount of money. This may have been the case a generation or more ago, but definitely not now. If only they could see the expense side of running a medical office. We need to get back to physicians caring for patients, rather than computers and insurance forms.” -05.05.2015 slmrn (comment on MedPage article)

HOW TO OPT-OUT OF MEDICARE1. Write your declaration of freedom

2. Notify your patients 3 or more months prior to opt-out date. Explain your rationale & invite discussion.

3. Mail signed opt-out affidavit to Medicare contractor (ex- Noridian) via certified mail MORE than 30 days before the next fiscal quarter. Also include a copy of your patient private contract

4. Once confirmation of receipt is received, call your carrier to make sure they are processing the opt-out (notate name and reference number)

5. 1 week prior to opt-out date, call again to check status (notate name and reference number)

6. Call again the following day (notate name and reference number)

7. Repeat 6 until you are able to obtain an opt-out confirmation letter

8. See patients on a direct-pay basis: obtain signed contracts from any Medicare patients prior to bringing them back to the treatment room

9. Clarify any questions before seeing patients

10. Make it VERY CLEAR that patients cannot send the bill to Medicare!

Nonparticipating Physician Opt-Out

• A nonparticipating physician may opt out of Medicare at any time in accordance with the following:

• The 2-year opt-out period begins the date the affidavit meeting the requirements of §40.9 is signed, provided the affidavit is filed within 10 days after the physician or practitioner signs his or her first private contract with a Medicare beneficiary.• If the physician or practitioner does not timely file any required affidavit, the 2-year opt-out period begins when the last such affidavit is filed. Any private contract entered into before the last required affidavit is filed becomes effective upon the filing of the last required affidavit and the furnishing of any items or services to a Medicare beneficiary under such contract before the last required affidavit is filed is subject to standard Medicare rules.

Medicare Benefit Policy Manual Chapter 15: 40.7 - Definition of a Private Contract (B3-

3044.7)

• A contract between a Medicare beneficiary and a physician who has opted out of Medicare for two years for all covered items and services the physician/practitioner furnishes to Medicare beneficiaries.

• Medicare beneficiary agrees to give up Medicare payment for services furnished by the physician and to pay the physician without regard to any limits that would otherwise apply to what the physician could charge. Pursuant to the statute, once a physician files an affidavit notifying the Medicare carrier that the he/she has opted out of Medicare, the physician is out of Medicare for two years from the date the affidavit is signed (unless the opt-out is terminated early according to§40.35, or unless the he/she fails to maintain opt-out (See §40.11)).

• After those two years are over, a physician could elect to return to Medicare or to opt out again.

• A beneficiary who signs a private contract with a physician/practitioner is not precluded from receiving services from other physicians and practitioners who have not opted out of Medicare.

Summary: Patient needs to sign a private contract before treatment. Contract is valid for 2 years. Keep a copy. Re-opt out and re-contract with patients every 2 years.

40.9 - Requirements of the Opt-Out AffidavitUnder 1802(b)(3)(B) of the Act, a valid affidavit must:• Be in writing and be signed by the physician/practitioner;• Contain the physician’s or practitioner’s full name, address, telephone number, national provider identifier (NPI) or billing number (if one has been assigned), or, if an NPI has not been assigned, the physician’s or practitioner’s tax identification number (TIN);• State that, except for emergency or urgent care services (as specified in §40.28), during the opt-out period the physician/practitioner will provide services to Medicare beneficiaries only through private contracts that meet the criteria of §40.8 for services that, but for their provision under a private contract, would have been Medicare-covered services;• State that the physician/practitioner will not submit a claim to Medicare for any service furnished to a Medicare beneficiary during the opt-out period, nor will the physician/practitioner permit any entity acting on the physician’s/practitioner’s behalf to submit a claim to Medicare for services furnished to a Medicare beneficiary, except as specified in §40.28;• State that, during the opt-out period, the physician/practitioner understands that the physician/practitioner may receive no direct or indirect Medicare payment for services that the physician/practitioner furnishes to Medicare beneficiaries with whom the physician/practitioner has privately contracted, whether as an individual, an employee of an organization, a partner in a partnership, under a reassignment of benefits, or as payment for a service furnished to a Medicare beneficiary under a Medicare Advantage plan;• State that a physician/practitioner who opts out of Medicare acknowledges that, during the opt-out period, the physician’s/practitioner’s services are not covered under Medicare and that no Medicare payment may be made to any entity for the physician’s/practitioner’s services, directly or on a capitated basis;• State on acknowledgment by the physician/practitioner to the effect that, during the opt-out period, the physician/practitioner agrees to be bound by the terms of both the affidavit and the private contracts that the physician/practitioner has entered into;• Acknowledge that the physician/practitioner recognizes that the terms of the affidavit apply to all Medicare-covered items and services furnished to Medicare beneficiaries by the physician/practitioner during the opt-out period (except for emergency or urgent care services furnished to the beneficiaries with whom the physician/practitioner has not previously privately contracted) without regard to any payment arrangements the physician/practitioner may make;• With respect to a physician/practitioner who has signed a Part B participation agreement, acknowledge that such agreement terminates on the effective date of the affidavit;• Acknowledge that the physician/practitioner understands that a beneficiary who has not entered into a private contract and who requires emergency or urgent care services may not be asked to enter into a private contract with respect to receiving such services and that the rules of §40.28 apply if the physician/practitioner furnishes such services;• Identify the physician/practitioner sufficiently so that the Medicare contractor can ensure that no payment is made to the physician/practitioner during the opt-out period; and• Be filed with all Medicare contractors who have jurisdiction over claims the physician/practitioner would otherwise file with Medicare and be filed no later than 10 days after the first private contract to which the affidavit applies is entered into.

Summary: READ THE INSTRUCTIONS, FOLLOW THE RULES.

40.8 - Requirements of a Private ContractA private contract under this section must:

• Be in writing and in print sufficiently large to ensure that the beneficiary is able to read the contract;

• Clearly state whether the physician/practitioner is excluded from Medicare under §§1128, 1156 or 1892 of the Act;

• State that the beneficiary or the beneficiary’s legal representative accepts full responsibility for payment of the physician’s or practitioner’s charge for all services furnished by the physician/practitioner;

• State that the beneficiary or the beneficiary’s legal representative understands that Medicare limits do not apply to what the physician/practitioner may charge for items or services furnished by the physician/practitioner;

• State that the beneficiary or the beneficiary’s legal representative agrees not to submit a claim to Medicare or to ask the physician/practitioner to submit a claim to Medicare;• State that the beneficiary or the beneficiary’s legal representative understands that Medicare payment will not be made for any items or services furnished by the physician/practitioner that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted;

• State that the beneficiary or the beneficiary’s legal representative enters into the contract with the knowledge that the beneficiary has the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted out of Medicare, and that the beneficiary is not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted out;

• State the expected or known effective date and expected or known expiration date of the opt-out period;

• State that the beneficiary or the beneficiary’s legal representative understands that Medigap plans do not, and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare;

• Be signed by the beneficiary or the beneficiary’s legal representative and by the physician/practitioner;

• Not be entered into by the beneficiary or by the beneficiary’s legal representative during a time when the beneficiary requires emergency care services or urgent care services. (However, a physician/practitioner may furnish emergency or urgent care services to a Medicare beneficiary in accordance with §40.28;)

• Be provided (a photocopy is permissible) to the beneficiary or to the beneficiary’s legal representative before items or services are furnished to the beneficiary under the terms of the contract;

• Be retained (original signatures of both parties required) by the physician/practitioner for the duration of the opt-out period;

• Be made available to CMS upon request; and

• Be entered into for each opt-out period.

OPT-OUT FAIL

• Entering into private contracts with Medicare beneficiaries prior to your opt-out date• Failure to submit an approved opt-out affidavit• Knowingly billing Medicare for services provided • Not abiding by emergency care billing rules

OPT OUT FAIL1. Any private contract that was entered into before the “Opt Out” affidavit was filed does not meet the

specifications of §40.8; (In order for a private contract with a beneficiary to be effective, the physician/practitioner must file an affidavit with all Medicare contractors to which the physician/practitioner would submit claims, advising that the physician/practitioner has opted out of Medicare. The affidavit must be filed within 10 days of entering into the first private contract with a Medicare beneficiary. Once the physician/practitioner has opted out, such physician/practitioner must enter into a private contract with each Medicare beneficiary to whom the physician/practitioner furnishes covered services (even where Medicare payment would be on a capitated basis or where Medicare would pay an organization for the physician’s or practitioner’s services to the Medicare beneficiary), with the exception of a Medicare beneficiary needing emergency or urgent care.

2. The physician/practitioner fails to submit the affidavit(s) in accordance with §40.9.B. If a physician fails to properly opt out in accordance with the above paragraphs of this section, the following will result:• The physician’s attempt to opt out of Medicare is nullified, and all of the private contracts between the physician and Medicare beneficiaries for the two-year period covered by the attempted opt out are deemed null and void;• The physician must submit claims to Medicare for all Medicare-covered items and services furnished to Medicare beneficiaries, including the items and services furnished under the nullified contracts.

• A nonparticipating physician is subject to the limiting charge provision. For items or services paid under the physician fee schedule, the limiting charge is 115 percent of the approved amount for nonparticipating physicians or practitioners. A participating physician is subject to the limitations on charges of the participation agreement the physician signed;

The physician/practitioner may neither bill nor collect an amount from the beneficiary except for applicable deductible and coinsurance amounts

THE LIGHT AT THE END OF THE TUNNEL

ATTORNEY2%

CHIROPRACTOR18%

INTERNET9%

CURRENT PATIENTS16%

WORD OF MOUTH8%

PHYSICAL THERAPIST25%

PCP14%

SPECIALIST 8%

LWSS NEW PATIENTREFERRAL SOURCES

SEPTEMBER 2015

InternetCurrent Pa-tientsWord of Mouth= 1/3 of refer-rals

CASH PRACTICE:HOW WILL PATIENTS FIND YOU?

CULTIVATE RAVING FANS

• Envision your favorite patient• That patient has awesome friends, family and co-workers!• Ask for their referrals• If you provide the best care and a valuable service, people will want to

recommend you

ONLINE PRESENCE

• WEBSITE• Inexpensive, DIY with Weebly, Wix, Wordpress

• BLOG• Organic content• Helps you communicate info to patients

• YELP• 20-30 somethings value reviews

• GOOGLE• Develop and manage your Google business page. Add photos & content

• FACEBOOK• Fun way to interact with both patients and community providers

USE GOOGLE TO YOUR ADVANTAGE